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SPECIAL AWARDS ISSUE
05.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
www.aad.org
GARGANTUAN
GROWING GENERIC PRICES
Soaring prices force dermatologists to
rethink common therapies 26
+
07 Coding
16 Research
18 Legal Issues
24 Practice Management
48 Academy News
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in this issue
from the editor
DEAR READERS,
Part of the art of keeping one’s
cool when in battle…
I
s realizing that victory is not always inevitable. I recently read a
biography about Stonewall Jackson; it was quite striking that he understood this paradigm well. Some battles went for the Union, while
others for the Confederacy, but it seems that he kept his cool regardless. It is said that his great talent was the ability to respond on the fly in
the midst of what must have been quite a confusing landscape. While I
personally believe that our country is much the better for the northern
success, I think that we can learn much from Jackson about handling
pressure under fire.
Many of us see ourselves in a battle against the escalating costs of generic meds. Normally
I don’t think much about my age, but I feel a bit old when I remember the cost of generics
when I finished my training. Doxycycline at six cents a pill was affordable for almost everyone
and tetracycline was even cheaper. Treating acne was not an expensive undertaking. Not so
today. As our feature on this topic explains these same pills, without further research and
discovery, have increased anywhere from 7000-18,000 percent! I feel a bit like my grandmother who used to tell me how during the depression a cup of soup cost five cents. I’m
sure your patients are complaining just like mine. Read our piece to understand the possible
causes: material shortages and consolidation of the pharmaceutical industry leading to fewer
companies making generics are on the table. It is mysterious to me that some generics have
remained inexpensive…why is clobetasol more expensive than betamethasone diproprionate,
for example? As a consequence of these costs the number of generics that I use is growing
smaller and smaller. Like Jackson, I think we need to figure out how to respond to this issue
and documenting what we are all seeing is a good start. We should be sending Adam Rubin’s
AAD Regulatory Policy Committee our examples and telling them of our ire.
Some of our battles have become unqualified successes. If you want to feel good, then
read the piece on sunscreens. We’re finally seeing the FDA speeding up the review process
which we hope will grant us access to better sunscreen products. It will be nice to not have to
mention to my patients traveling to Canada for a summer holiday that it might be worth their
while to pick up sunscreen as part of their souvenirs! This battle to get the newer sunscreen
ingredients approved in this country has been long fought and, therefore, the fruit of this
labor is especially sweet. I, for one, can’t wait to see some new sunscreen ingredients hit the
market.
So while one battle on sunscreen ingredients starts to wind down, the next on costs of
generics winds up. This, like many of our issues, is best not fought alone. Happily we are not
the only prescribers of the tetracycline family of meds…they can be helpful for MRSA infections amongst other things. Stonewall Jackson ultimately was killed by friendly fire. Let’s not
make that the model for our fight. Let’s hope that all of us in the house of medicine are on the
same side on this one.
Enjoy your reading.
VOL. 25 NO. 5 | MAY 2015
PRESIDENT
Mark Lebwohl, MD
EXECUTIVE DIRECTOR
Elaine Weiss, JD
PUBLISHER
Lara Lowery
EDITOR
Katie Domanowski
MANAGING EDITOR
Richard Nelson, MS
ASSISTANT MANAGING EDITOR
Victoria Houghton, MPA
DESIGN MANAGER
Ed Wantuch
EDITORIAL DESIGNER
Theresa Oloier
DESIGN TEAM
Nicole Torling
ADVERTISING SPECIALIST
Carrie Parratt
PHYSICIAN EDITOR
Abby Van Voorhees, MD
PHYSICIAN REVIEWER
Barbara Mathes, MD
CONTRIBUTING WRITERS
Jan Bowers
Ruth Carol
Jeanine Coffman
Susan Jackson
Alexander Miller, MD
Victoria Pasko
Rob Portman, JD
EDITORIAL ADVISORS
Lakshi Aldredge, MSN, ANP-BC
Annie Chiu, MD
Jeffrey Dover, MD
Rosalie Elenitsas, MD
John Harris, MD, PhD
Chad Hivnor, MD
Sylvia Hsu, MD
Risa Jampel, MD
Michel McDonald, MD
Christen Mowad, MD
Robert Sidbury, MD
Oliver Wisco, DO
Printed in U.S.A. Copyright © 2015 by the
American Academy of Dermatology Association
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MISSION STATEMENT: Dermatology World is
published monthly by the American Academy
of Dermatology Association. Through insightful
analysis of the trends that affect them, it provides
members with a trusted, inside source for
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2 DERMATOLOGY WORLD // May 2015
ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR
www.aad.org/dw
HOT
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DERMW2015CA
05.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
features
www.aad.org
depts
02
FROM THE EDITOR
07
CRACKING THE CODE
Nail it.
“Some of these
generic drugs seem
to disappear from
pharmacy shelves 26
or skyrocket in
SPECIAL AWARDS ISSUE
price suddenly and
GARGANTUAN GROWING GENERIC
PRICES
without notice
Soaring prices force dermatologists to rethink
common therapies
or any predictable
patterns.”
COVER STORY
BY RUTH CAROL
4 DERMATOLOGY WORLD // May 2015
18
LEGALLY SPEAKING
Power at the bargaining
table: Antitrust risks and
alternatives for
dermatologists.
22
BALANCE IN PRACTICE
24
Profiling the missing pieces and implications of
Medicare’s physician payment data
Managing a small practice.
Legislation creates timelines for FDA review
2011 Ozzie Silver Award,
Best Redesign:
Association/Non-profit.
2014 Eddie Honorable
Mention, Association/
Non-profit video
ACTA ERUDITORUM
Laser litigation most
common in nontraditional settings.
DECODING DATA DIVORCED
FROM CONTEXT
A FASTER PIPELINE
2013 HOW InHOWse
Design Award –
Cover/Feature Design
16
34
40
2011, 2012, 2013, and 2014
Graphic Design USA Award –
Cover/Feature Design.
2014 Graphic Design USA
American Web Design Award
ROUNDS
AAD award winners.
Sandy recollections.
BY VICTORIA HOUGHTON
2014 AM&P Excel Bronze
Award, Design Excellence
14
BY JAN BOWERS
ANSWERS IN PRACTICE
46
FROM THE PRESIDENT
48
ACADEMY UPDATE
Committee
appointments, more.
52
FACTS AT YOUR
FINGERTIPS
Teen tanning dropped
from 2009 to 2013;
sunscreen use flat.
www.aad.org/dw
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INDICATION
ONEXTON (clindamycin phosphate and benzoyl
peroxide) Gel, 1.2%/3.75% is indicated for the
topical treatment of acne vulgaris in patients
12 years of age or older.
IMPORTANT SAFETY INFORMATION
• ONEXTON Gel is contraindicated in patients
with a known hypersensitivity to clindamycin,
benzoyl peroxide, any component of the
formulation, or lincomycin.
• ONEXTON Gel is contraindicated in patients
with a history of regional enteritis, ulcerative
colitis, or antibiotic-associated colitis.
• Diarrhea, bloody diarrhea, and colitis
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systemic clindamycin. ONEXTON Gel should
be discontinued if significant diarrhea occurs.
• Orally and parenterally administered
clindamycin has been associated with severe
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• Anaphylaxis, as well as other allergic
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been reported in postmarketing use of
products containing clindamycin/benzoyl
peroxide. If a patient develops symptoms
•
•
•
•
•
of an allergic reaction such as swelling and
shortness of breath, they should be instructed
to discontinue use and contact a physician
immediately.
The most common local adverse reactions
experienced by patients in clinical trials were
mild and moderate erythema, scaling, itching,
burning and stinging.
ONEXTON Gel should not be used in
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ONEXTON Gel should be used during
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Gel while nursing, taking into account the
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Please see Brief Summary of Prescribing Information on the following page.
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or its affiliates. Any other product or brand names and logos are
the property of their respective owners.
© 2015 Valeant Pharmaceuticals North America LLC. DM/ONX/15/0036
®
S:6.75”
BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION
Neuromuscular Blocking Agents
This Brief Summary does not include all the information needed to use ONEXTON
Gel safely and effectively. See full prescribing information for ONEXTON Gel.
Clindamycin has been shown to have neuromuscular blocking properties that may
enhance the action of other neuromuscular blocking agents. ONEXTON Gel should be
used with caution in patients receiving such agents.
ONEXTON™ (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75%, for
topical use
Initial U.S. Approval: 2000
CONTRAINDICATIONS
Hypersensitivity
ONEXTON Gel is contraindicated in those individuals who have shown hypersensitivity
to clindamycin, benzoyl peroxide, any components of the formulation, or lincomycin.
Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported
in postmarketing use with ONEXTON Gel [see Adverse Reactions]
WARNINGS AND PRECAUTIONS
Colitis/Enteritis
Systemic absorption of clindamycin has been demonstrated following topical use of
clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous
colitis) have been reported with the use of topical and systemic clindamycin. If
significant diarrhea occurs, ONEXTON Gel should be discontinued.
Severe colitis has occurred following oral and parenteral administration of
clindamycin with an onset of up to several weeks following cessation of therapy.
Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong
and/or worsen severe colitis. Severe colitis may result in death.
Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated
colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal
cramps and may be associated with the passage of blood and mucus. Stool cultures for
Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically.
Ultraviolet Light and Environmental Exposure
Minimize sun exposure (including use of tanning beds or sun lamps) following drug
application [see Nonclinical Toxicology].
ADVERSE REACTIONS
The following adverse reaction is described in more detail in the Warnings and
Precautions section of the label:
Colitis [see Warnings and Precautions].
Table 1: Local Skin Reactions - Percent of Subjects with Symptoms Present.
Results from the Phase 3 Trial of ONEXTON Gel 1.2%/3.75% (N = 243)
Before Treatment
(Baseline)
Maximum During
Treatment
End of Treatment
(Week 12)
Mild Mod.* Severe
Mild Mod.* Severe
Mild Mod.* Severe
Erythema
20
6
0
28
5
<1
15
2
0
Scaling
10
1
0
19
3
0
10
<1
0
Itching
14
3
<1
15
3
0
7
2
0
Burning
5
<1
<1
7
1
<1
3
<1
0
Stinging
5
<1
0
7
0
<1
3
0
<1
*Mod. = Moderate
Postmarketing Experience
Because postmarketing adverse reactions are reported voluntarily from a population
of uncertain size, it is not always possible to reliably estimate their frequency or
establish a causal relationship to drug exposure.
Anaphylaxis, as well as allergic reactions leading to hospitalizations, has been reported
in postmarketing use of products containing clindamycin phosphate/benzoyl peroxide.
DRUG INTERACTIONS
Erythromycin
Avoid using ONEXTON Gel in combination with topical or oral erythromycincontaining products due to its clindamycin component. In vitro studies have shown
antagonism between erythromycin and clindamycin. The clinical significance of this in
vitro antagonism is not known.
Concomitant Topical Medications
Concomitant topical acne therapy should be used with caution since a possible
cumulative irritancy effect may occur, especially with the use of peeling, desquamating,
or abrasive agents. If irritancy or dermatitis occurs, reduce frequency of application
or temporarily interrupt treatment and resume once the irritation subsides. Treatment
should be discontinued if the irritation persists.
Nursing Mothers
It is not known whether clindamycin is excreted in human milk after topical application
of ONEXTON Gel. However, orally and parenterally administered clindamycin has been
reported to appear in breast milk. Because of the potential for serious adverse reactions
in nursing infants, a decision should be made whether to use ONEXTON Gel while
nursing, taking into account the importance of the drug to the mother.
Pediatric Use
Safety and effectiveness of ONEXTON Gel in pediatric patients under the age of 12
have not been evaluated.
Geriatric Use
Clinical trials of ONEXTON Gel did not include sufficient numbers of subjects aged 65
and older to determine whether they respond differently from younger subjects.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity, mutagenicity and impairment of fertility testing of ONEXTON Gel have
not been performed.
Benzoyl peroxide has been shown to be a tumor promoter and progression agent in
a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg
administered topically twice per week for 20 weeks induced skin tumors in transgenic
Tg.AC mice. The clinical significance of this is unknown.
Carcinogenicity studies have been conducted with a gel formulation containing
1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in
mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day
(1.8, 5.4, and 30 times amount of clindamycin and 2.4, 7.2, and 40 times amount of
benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel
based on mg/m2, respectively) did not cause any increase in tumors. However, topical
treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl
peroxide at doses of 100, 500, and 2000 mg/kg/day caused a dose-dependent increase in
the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal
carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment
with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12
times amount of clindamycin and 1.6, 4.8, and 16 times amount of benzoyl peroxide
in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/
m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week
dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by
12 weeks of observation), the median time to onset of skin tumor formation decreased
and the number of tumors per mouse increased relative to controls following chronic
concurrent topical administration of the higher concentration benzoyl peroxide formulation
(5000 and 10000 mg/kg/day, 5 days/week) and exposure to ultraviolet radiation.
Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome
aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety
of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all
investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells.
Fertility studies have not been performed with ONEXTON Gel or benzoyl peroxide,
but fertility and mating ability have been studied with clindamycin. Fertility studies in
rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times
the amount of clindamycin in the highest recommended adult human dose of 2.5 g
ONEXTON Gel, based on mg/m2) revealed no effects on fertility or mating ability.
PATIENT COUNSELING INFORMATION
See FDA-approved patient labeling (Patient Information).
Distributed by:
Valeant Pharmaceuticals North America LLC, Bridgewater, NJ 08807
Manufactured by:
Contract Pharmaceuticals Limited Mississauga, Ontario, Canada L5N 6L6
U.S. Patents 5,733,886 and 8,288,434
Issued 11/2014
9389300
DM/ONX/14/0031(1)
S:9.75”
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction
rates observed in clinical trials of a drug cannot be directly compared to rates observed in
the clinical trials of another drug and may not reflect the rates observed in clinical practice.
These adverse reactions occurred in less than 0.5% of subjects treated with ONEXTON
Gel: burning sensation (0.4%); contact dermatitis (0.4%); pruritus (0.4%); and rash (0.4%).
During the clinical trial, subjects were assessed for local cutaneous signs and
symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions
either were the same as baseline or increased and peaked around week 4 and were
near or improved from baseline levels by week 12. The percentage of subjects that had
symptoms present before treatment (at baseline), during treatment, and the percent
with symptoms present at week 12 are shown in Table 1.
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy Category C.
There are no adequate and well-controlled studies in pregnant women treated with
ONEXTON Gel. ONEXTON Gel should be used during pregnancy only if the potential
benefit justifies the potential risk to the fetus.
Animal reproductive/developmental toxicity studies have not been conducted with
ONEXTON Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin
performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120
times amount of clindamycin in the highest recommended adult human dose based
on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40
times the amount of clindamycin in the highest recommended adult human dose
based on mg/m2, respectively) revealed no evidence of teratogenicity.
cracking the code
coding tips
BY ALEXANDER MILLER, MD
Nail it
ALEXANDER MILLER, MD, addresses important coding and documentation questions each month in Cracking the Code.
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the
AMA-CPT® Advisory Committee.
A prospective patient opens a top freezer door, reaches for ice cream, but in the process dislodges a frozen chicken that
tumbles out, falling directly upon a bare big toe. A painful subungual hematoma leads to a frantic visit to you, the patient’s established dermatologist. Lacking a drill but being well stocked with paper clips, you unwind a paper clip, heat its tip with a lighter
used for KOH slide preps, and gently burn through the nail plate, liberating a geyser of dark blood and immediately relieving the
pain. You then bill for the procedure with Current Procedure Terminology (CPT) code 10140, “Incision and drainage of hematoma, seroma or fluid collection”. You did an exquisitely effective therapeutic procedure, but did you bill correctly?
The CPT indicates that one should select a code that most accurately specifies, rather than approximates, a performed service. One finds that the CPT has a section devoted to nail procedures: CPT 11720 – 11765, which lists the following code: 11740,
Evacuation of subungual hematoma. Thus, the more precise code 11740, rather than 10140, should have been used to characterize the hematoma extrusion in the above vignette.
The “Nails” section of the CPT lists nail-specific procedural codes. The following is a list extracted from the CPT®.
11720 Debridement of nail(s) by any method(s); 1-5
11721
6 or more
11730 Avulsion of nail plate, partial or complete, simple; single
11732 each additional nail plate (List separately in addition to code for primary procedure)
11740 Evacuation of subungual hematoma
11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;
11752 with amputation of tuft of distal phalanx
11755 Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail fold(s) (separate procedure)
11760 Repair of nail bed
11762 Reconstruction of nail bed with graft
11765 Wedge excision of skin of nail fold (eg, for ingrown toenail)
Example 1: You obtain a smear swab from the proximal nail fold area of an exudative paronychia on a commercially insured patient and do an in-office KOH processing and examination of the specimen for the presence or absence of Candidal organisms.
You bill CPT 87220 for the KOH examination.
Answer: Incorrect. The CPT lists two potential codes for KOH processing. CPT 87220 is for skin, hair, or nails tissue KOH slide examination. In this case the specimen is of a wet mount smear of exudate, rather than of actual tissue. Consequently, the more appropriate
CPT code is 87210, “wet mount for infectious agents (e.g., saline, India ink, KOH preps).”
Example 2: You obtain the same swab specimen as in Example 1, but from a Medicare insured patient. You bill the Medicare Administrative Contractor the Healthcare Common Procedure System (HCPCS) code Q0112, as Medicare preferentially recognizes
this code, published in the HCPCS manual.
DERMATOLOGY WORLD // May 2015 7
cracking the code continued
coding tips
Answer: Correct. HCPCS code Q0112 is defined as: “All potassium hydroxide (KOH) preparations”. This should be used for Medicare patients
instead of the CPT code. Note that there is another HCPCS code, Q0111, defined as, “Wet mounts, including preparations of vaginal, cervical or
skin specimens.” As in this example a KOH examination was done, code Q0112 is the appropriate choice.
Example 3: A patient’s great toenail contains white spots of uncertain cause. Are they caused by white superficial onychomycosis, or are
they leukonychia due to trauma? You use nail nippers to remove a portion of the affected nail plate and submit it for histologic processing and PAS staining for fungus identification. You bill CPT 11755 for the nail biopsy and 88312-26 for the professional component of
interpretation and report of a Group I for microorganisms PAS special stain.
Answer: Incorrect. CPT code 11755 describes “Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate
procedure).” The October 2004 CPT Assistant, page 14, indicates that this biopsy procedure code is not appropriate for reporting the production
of nail clippings or scrapings for fungal cultures, KOH preps, or stains including PAS. Obtaining pieces of nail is included in the evaluation and
management process and is not separately billable. Histologic processing, including the preparation of PAS stained nail on a microscope slide and
interpretation, are separately billable with CPT 88312 global, appended TC for the technical component only, or appended 26 for the professional
component, including the generation of a report.
Example 4: You relieve pain and tenderness caused by thick, yellowed, dystrophic great toe nails by debriding and trimming the nails
with nail nippers, process some of the clippings for KOH prep examination, and send others for a fungal culture. You then bill CPT
11720 for the debridement and 87220 (or HCPCS Q0112 for Medicare patients) for the KOH prep.
Answer: Correct. CPT 11720 indicates “Debridement of nail(s) by any method(s); 1 to 5.” This includes the debridement of fungal infected nails,
hypertrophic nails, and dystrophic nails. This code does not relate to what is done with the removed nail portions. However, if those are sent for
further examination, such as KOH prep processing, then the appropriate code for the laboratory procedure should be specified.
Example 5: You remove the entire lateral longitudinal length of a painful ingrown toenail and cauterize the nail matrix of the removed portion of nail with phenol. You bill CPT 11750, “Excision of nail and nail matrix, partial or complete,” for the nail removal and matrixectomy.
Answer: Correct. Although the procedure that was done did not include an actual excision of the matrix, CPT code 11750 is appropriate. This is
corroborated in the CPT Assistant, December 2002, page 4, which states that code 11750 includes a destruction of the matrix with surgical, laser,
electrocautery, or chemical techniques.
Example 6: Your dear friend with excellent insurance pops in with a traumatic partial nail avulsion and laceration of the distal dorsal finger extending into the nail bed. You remove the nail and meticulously sew together the nail bed as well as the laceration on the adjoining
proximal finger. You bill CPT 11760, repair of nail bed, to insurance.
Answer: Partially Correct. In addition to repairing the nail bed, specified with CPT 11760, you also repaired the dorsal finger skin beyond that
of the nail unit. It is appropriate to separately code for this procedure with a simple, intermediate, or complex repair code corresponding to the
complexity and measured length of the repair.
As in all cases, the assignment of a CPT code does not guarantee reimbursement, as individual insurance company coverage criteria must be
met in order to qualify for payment. Some Medicare Administrative Contractors maintain Local Coverage Determinations (LCD) specifically dealing with nail debridement.
Example 7: You avulse the nail in order to expose a nail bed lesion and do an incisional biopsy that you suture shut. You bill CPT 11730
for the nail plate avulsion and 11755 for the nail unit biopsy.
Answer: Incorrect. Only CPT 11755 should be billed, as the nail plate avulsion (and replacement, if done) is included in the 11755 code descriptor,
which also includes suturing of the biopsied tissue (CPT Assistant, October 2004). dw
8 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
Prescribe
Finacea first
®
© 2014 Bayer HealthCare Pharmaceuticals Inc. Bayer, the Bayer Cross, Finacea
and the Finacea logo are registered trademarks of Bayer. All rights reserved.
PP-825-US-0202 | September 2014
rounds
Academy honors member
contributions to dermatology
E
very year, the Academy recognizes the invaluable contributions of its members through a number of prestigious awards. Below,
Dermatology World profiles this year’s recipients of several of these awards. Learn more about the Academy’s awards, grants, and
scholarships at www.aad.org/members/awards-grants-scholarships. – VICTORIA HOUGHTON
June K. Robinson, MD,
wins Academy Gold Medal
IN RECOGNITION OF HER VISIONARY LEADERSHIP in dermatology, strong focus on skin cancer prevention and detection, and dedication as an educator, clinician, and editor,
June K. Robinson, MD, has earned the American Academy
of Dermatology’s Gold Medal award.
Dr. Robinson currently serves as research professor of
dermatology at Northwestern University Feinberg School
of Medicine. She received this award for her past work as
secretary-treasurer and member of the AAD’s Board of
Directors, her exemplary service as a past president of the
American Cancer Society – Illinois Division, the Women’s
Dermatologic Society, the American Society for Dermatologic Surgery, and for her many roles at Loyola University
Chicago, Northwestern University Medical School, Northwestern Medical Faculty Foundation, and the Northwestern
Memorial Hospital Cancer and Research Committees.
Dr. Robinson is also the current editor of JAMA Dermatology (formerly Archives of Dermatology) and an editor for
Surgery of the Skin: Procedural Dermatology and the Cancer
of Skin as well as the author of more than 170 peer-reviewed
publications and numerous textbook chapters. The Gold
Medal award is the Academy’s highest honor.
10 DERMATOLOGY WORLD // May 2015
Academy’s Master Dermatologist
awarded to Roy S. Rogers III, MD
IN RECOGNITION OF HIS EXTENSIVE RESEARCH, teachings,
and publications, Roy S. Rogers III, MD, has earned the
Academy’s Master Dermatologist Award. Dr. Rogers serves
as professor of dermatology at the Mayo Clinic College
of Medicine and a consultant in dermatology at the Mayo
Clinic in Arizona. Dr. Rogers served as dean of students
and then academic dean of the Mayo Medical School from
1982 to 1989, and then served as dean of the Mayo School
of Health-Related Sciences for 10 years. He was recognized
as a Distinguished Educator by Mayo Clinic Rochester in
2004. He is recognized as an authority in oral medicine,
pathology, and dermatology and has edited three volumes
of the Dermatology Clinics and co-authored three books
and many scholarly publications. Dr. Rogers has taught in
55 countries and has been recognized by the International
League of Dermatological Societies for his dedication to
international dermatological education.
The Master Dermatologist award started 30 years ago
and recognizes an Academy member who, throughout the
span of his or her career, has made significant contributions
to the specialty of dermatology, as well as to the leadership
and/or educational programs of the American Academy of
Dermatology.
www.aad.org/dw
celebrating members
Ali Jabbari, MD, PhD, and John Harris, MD, PhD,
receive Young Investigators in Dermatology awards
ALI JABBARI, MD, PHD, AND JOHN HARRIS, MD, PHD, have received the 2015 Young Investigators in
Dermatology awards. The awards recognize outstanding basic and clinical/translational research
by young dermatology investigators in the U.S. and Canada, and the dermatology departments that
support their efforts. The purpose of the award is to acknowledge a winner’s research contribution that furthers the improvement of diagnosis and therapeutics in the practice and science of
dermatology.
Dr. Jabbari conducted a study to better understand the cellular and molecular drivers of
alopecia areata in order to determine new therapeutic targets. The study showed that two drugs
— ruxolitinib and tofacitinib — not only prevented the development of alopecia but, when used as
a topical, were effective in treating alopecia. Dr. Jabbari currently serves as assistant professor of
dermatology at Columbia University Medical Center. He received his medical degree and doctorate
in immunology at the University of Iowa, Carver College of Medicine, and completed his dermatology residency at New York University.
Dr. Harris conducted a study to identify the pathways involved in the development of vitiligo to
develop new treatments for the disease. The study showed that deactivating the CXCL10 protein,
or obstructing its receptor CXCR3, is a “promising treatment strategy” for patients with vitiligo.
Dr. Harris currently serves as assistant professor in the department of medicine in the division of
dermatology at the University of Massachusetts Medical School, and is also director of the Vitiligo
Clinic and Research Center at UMass. He received his medical degree and doctorate in molecular
medicine at UMass, and completed his dermatology residency at the University of Pennsylvania.
DERMATOLOGY WORLD // May 2015 11
rounds continued
Advocate of the Year award goes to Alex Gross, MD
IN RECOGNITION OF HIS OUTSTANDING COMMITMENT to advocating on behalf of patients and the specialty in
Georgia and at the federal level, Alex Gross, MD, has been selected as the 2014 Advocate of the Year. Each year,
the Academy recognizes a member who undertakes a significant amount of grassroots advocacy activities at the
state and/or federal level, on behalf of the specialty. Dr. Gross was instrumental in the passing of legislation that
requires non-physicians who operate cosmetic lasers to be licensed and shepherded successful passage of Georgia’s under-14 indoor tanning restrictions. Dr. Gross is the current president of the Georgia Society of Dermatology and Dermatologic Surgery, and is in private practice in Cumming, Georgia.
Robert Kirsner, MD, honored with Thomas G. Pearson Award
ROBERT KIRSNER, MD, IS THE 2015 RECIPIENT of the Academy’s prestigious Thomas G. Pearson, EdD, Memorial Education Award. The Pearson Award recognizes a member of the Academy who has advanced the organization’s educational mission through significant contribution of time, development of educational programs,
coordination of educational activities, and more. Dr. Kirsner has been integral in the development of many
continuing medical education and maintenance of certification activities. Dr. Kirsner is the chair of the Academy’s Council on Education and Maintenance of Certification, and held the endowed Stiefel Laboratories chair
in dermatology in the department of dermatology and cutaneous surgery at the University of Miami’s Miller
School of Medicine, until recently, when he was appointed interim chair of the department of dermatology and
became the Harvey Blank Professor. He currently serves as director of the University of Miami Hospital Wound
Center and chief of dermatology at the University of Miami Hospital. Dr. Kirsner serves on the editorial boards
for a number of journals including the JID, JAMA Dermatology, and Wound Repair and Regeneration.
Established in 2002, the Pearson Award also serves as a memorial to the late Dr. Thomas G. Pearson, who
served as the Academy’s director of education from 1987 to 2001.
12 DERMATOLOGY WORLD // May 2015
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celebrating members
Arnold P. Gold Foundation for Humanism in Medicine award
goes to James O. Ertle, MD
IN RECOGNITION OF HIS COMMITMENT to compassionate, patient-centered care, James O. Ertle, MD, has received
the Arnold P. Gold Foundation award. Dr. Ertle has been in private practice in Hinsdale, Illinois and on the faculty
of Rush Medical School for 40 years. In 2003, Dr. Ertle established an AAD program dedicated to providing care in
Haiti twice per year. Additionally, Dr. Ertle served as president of the Chicago, Illinois, and Great Lakes dermatological societies, and was instrumental in the passage of laws in Illinois regulating indoor tanning and tattoo parlors.
The Arnold P. Gold Foundation began more than 20 years ago with the goal of restoring a more effective
balance between the cutting-edge science of medicine and compassionate patient care. The foundation’s main
objective is to ensure that physicians become mindful of the life context of health and illness, and become skillful
in the habit of humanism, or how to communicate effectively and empathically to help patients heal.
Jonathan Weiss, MD, earns Rising Star in Education award
JONATHAN WEISS, MD, HAS RECEIVED the Academy’s Rising Star in Education Award. This award is presented
to a medical student, dermatology resident, or a doctor in a fellowship in recognition of exceptional contributions to the Academy’s continuing professional development program.
Dr. Weiss is one of two chief residents in dermatology at the University of Miami/Jackson Memorial Hospital. Dr.
Weiss began volunteering with the Academy in 2012 as a resident editor for Dialogues in Dermatology, a role in which
he has provided commentaries on issues including Technology Working for You, Skin Cancers in Organ Transplant
Recipients, Update on the Treatment of Cutaneous T Cell Lymphoma, and Early Diagnosis of Melanoma. Dr. Weiss
has also published a variety of papers. In 2011, Dr. Weiss’ abstract Primary mucinous carcinoma of the skin versus
metastatic mucinous adenocarcinoma was accepted for oral presentation for the Gross and Microscopic symposium at
the Annual Meeting. Dr. Weiss’s research interests include epidemiological research on racial disparities in sun-safe
behaviors and outcomes in melanoma and non-melanoma skin cancers. His clinical interests include dermatologic/
Mohs surgery, the management of advanced non-melanoma skin cancers and skin cancers in transplant patients, as
well as pigmented lesions/melanoma. Dr. Weiss aspires to establish a career in academic dermatology where he can
focus on the above research and clinical interests as well as resident and medical student education.
This award is only provided to those who have made exceptional contributions to the Academy’s educational
program, and as such is not always awarded every year.
DERMATOLOGY WORLD // May 2015 13
rounds continued
news in brief
Indoor tanning legislation builds on 2014 momentum
STATE NEWS ROUNDUP
IN 2014, THE AADA advocated for legislation
in 26 states and the District of Columbia
that would restrict indoor tanning for minors. By the end of the year, five states and
the District of Columbia passed under-18
restrictions, and five other states had some
form of age restriction — varying from
parental consent requirements to under-17
bans. Legislatures across the country used
that momentum to introduce a handful of
under-18 bills in January. However, given
the constraints of short legislative sessions,
only six states have indoor tanning legislation in play.
Bills that have been signed into law
In Idaho, existing law prohibits minors from getting tattoos, body piercings, or brandings without parental consent
and prohibits them entirely for minors under 14. Working closely with the Idaho dermatologists, the Idaho Medical
Association (IMA) was successful in passing legislation to add indoor tanning to that statute. The AADA provided
strategic guidance and resources to IMA and the state society.
Bills that have passed out of committee
A coalition has formed in Maine to advocate for under-18 legislation that includes the Maine Dermatological Society,
the Maine chapter of the American Academy of Pediatrics, the American Cancer Society-Cancer Action Network
(ACS-CAN), and the Maine Medical Association. The AADA has been actively engaged in its support of the bill,
activating grassroots and sending a letter of support. The bill passed a joint committee and awaits a vote before the
full legislature. Similar legislation passed in 2013 but was vetoed by the governor. An under-18 bill in North Carolina
has been reintroduced and passed committee. The bill passed the House in 2014 but was unable to gain traction in
the Senate.
Bills that have passed out of one chamber
New Hampshire’s under-18 legislation has passed the House and will now face the Senate.
Bills awaiting a committee or chamber vote
Legislation in Oklahoma and Kansas would restrict minors under 18 from indoor tanning. Legislation in Florida
would also restrict minors under the age of 18, but contains an exemption if the minor has obtained a physician prescription. These bills have not moved yet.
Bills that have died
Under-18 legislation in Kentucky passed the House, but failed to receive action in the Senate before the session
adjourned for the year. Iowa’s under-18 legislation passed out of both chambers’ committees, but an amended House
version failed to receive a hearing before the state’s deadline. The Montana legislature considered two indoor tanning bills: an under-18 bill and a parental consent bill. The AADA actively supported the under-18 bill, but it died in
committee. Under-18 legislation in Mississippi and Arizona died shortly after introduction as well. The AADA also
worked with a large coalition in Maryland — that included MedChi, the Maryland Dermatologic Society, and the ACSCAN — to advance two under-18 bills. Despite the AADA’s targeted grassroots advocacy efforts and strong presence at
committee hearings that included testimony from patients and two AADA members, the Senate legislation failed in
committee, thus killing the House bill’s chances. The AADA initially supported under-18 legislation in South Dakota;
however, the legislation was amended down to parental consent only, and failed in the full House. – VICTORIA PASKO dw
14 DERMATOLOGY WORLD // May 2015
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acta eruditorum
Q&A
Laser litigation
most common in
non-traditional
settings
IN THIS MONTH’S ACTA ERUDITORUM COLUMN,
Physician Editor Abby S. Van Voorhees, MD, talks with
Mathew Avram, MD, about his two recent articles, “FDA
MAUDE data on complications with lasers, light sources, and
energy-based devices” in Lasers in Surgery and Medicine and
“Increased risk of litigation associated with laser surgery by
nonphysician operators” in JAMA Dermatology.
DR. VAN VOORHEES: Let’s start with your
recent paper on the review of complications
associated with lasers, light sources, and
energy-based devices. All would agree
that the use of non-invasive procedures
has become increasingly popular, so
understanding the risks associated
with these procedures is of paramount
importance. Let’s start by your telling us
what database you utilized for your study.
DR. AVRAM: We used the Manufacturer and
User Facility Device Experience (MAUDE)
database. This is the primary database with
which the FDA gathers complications with
medical devices. It is generated by reports
by patients, physicians, and industry.
MAUDE is an important database because
it’s the largest one devoted to complications
with lasers, light sources, and energy-based
devices within the field of dermatology.
Therefore it was important for us to take a
look at the incidence of these complications
and side effects and seek to determine
which were the most common, and which
were surprising, in order to educate
physicians and non-physicians using these
devices as to the relative risks associated
with treating patients.
DR. VAN VOORHEES: What did you find were
the most common adverse events seen
overall? Are there differences between the
various types of instruments?
DR. AVRAM: Laser hair removal had the most
adverse events. This isn’t surprising because
laser hair removal is the most common use
of lasers in medicine. Depending on the
devices, the wavelengths, or the light source
devices that were being used, there were
differences in the reported adverse side
effects. This can be attributed to the design
of the devices as well as the inappropriate
use of these devices. It can be difficult to
determine whether it’s the device or the
operator that’s at fault.
16 DERMATOLOGY WORLD // May 2015
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research in practice
DR. VAN VOORHEES: Did any one type of
laser or light source have more medical
device reports (MDRs) than the others? Is
there any specific treatment type that had a
greater risk?
DR. AVRAM: We didn’t find red flags with
regard to the different devices. The most
important take-away from our review of
the database is that there were a number
of side effects for these devices related
to dermatologic treatment, thus, it’s
important to be aware that all of them carry
some degree of side effects. While some
of the devices have more inherent risk
than others, it’s important to note that the
inappropriate use of any of these devices,
particularly in the hands of operators with
less training and skill in the field, leads
to a particularly high risk for adverse side
effects.
DR. VAN VOORHEES: How reliable is this
data? Are physicians reporting their
complications reliably?
DR. AVRAM: While it’s a large and
important database due to the sheer
volume of reports within it, there are
important limitations. First, it’s based on
the reports of physicians, operators, and
industry. It’s fair to say that many operators
of these devices do not report all of the
adverse side effects that occur. This alone
detracts from the overall value of the data.
Further, the reports vary with regard to
their detail; unfortunately, some have
little detail regarding the precise source
of the side effect. Nevertheless, MAUDE
is an important database to examine — it
encompasses a huge number of treatments
and is the largest registry of reported
side effects in our field. It is crucial for
understanding the methods for employing
best practices for patient safety and
avoiding common side effects with the use
of lasers, light sources, and energy-based
devices.
DR. VAN VOORHEES: Now let’s switch to
talking about your paper on trends seen
associated with the use of laser surgery.
You mention that the number of cases
performed by non-physicians has expanded
over the past decade or so. Has this change
been substantial? Do you see it continuing?
DR. AVRAM: The change in the proportion
of non-physician operator (NPO) litigation
has been explosive over a short period
of time. There has been a tremendous
increase in litigation against NPOs due to
injuries that have occurred as a result of
laser, light source, and energy-based device
treatments of skin conditions. This trend
is particularly alarming because it comes
at a time when there are great differences
as to the degree of government regulation
regarding who can operate these devices
and what supervision, if any, is required.
These differences are governed by state law.
DR. VAN VOORHEES: Who qualifies as
an NPO? Were there differences among
different non-physicians?
DR. AVRAM: Any non-physician would
fall into this classification, whether a
nurse practitioner or physician assistant
or an aesthetician or electrologist. In the
legal database we queried, sometimes
it was difficult to tease out the details.
The information was not robust enough
to generate reliable data differentiating
among different types of NPOs.
DR. VAN VOORHEES: Is the increase in
litigation especially true with any specific
types of laser procedures?
DR. AVRAM: The most common source of
injury is laser hair removal. This is in part
true because it’s the most common use of
lasers in medicine. But it’s important to
note that the proportion of injuries that
are happening within laser hair removal
among NPOs is significantly out of
proportion to the number of procedures
that NPOs are performing. In other words,
the trends for increasing litigation are not
solely related to the fact that there are more
of these procedures being performed; the
growth in litigation is disproportionately
taking place in situations where NPOs are
performing the procedures. More people
are getting injured and they’re suing.
DR. VAN VOORHEES: As more physicians
delegate these procedures to NPOs has
there been a correlation in lawsuits?
DR. AVRAM: There’s been an increase in
the number of lawsuits as physicians
have delegated these procedures. It’s
important to note, though, that the largest
growth in litigation associated with these
procedures being delegated is among
NPOs performing these procedures
in non-traditional medical settings,
such as medispas, where the amount
of supervision, if any, is less than that
found in a traditional physician’s office
or hospital. That’s where we’re seeing the
biggest growth.
To be clear, these injuries are
happening in all settings. They’re
happening with dermatologists and plastic
surgeons performing these procedures
themselves. They’re happening more
frequently when delegated to NPOs
performing these procedures under
supervision in medical practices. But
they’re happening most commonly —
alarmingly, but perhaps not surprisingly
— in situations where there is less medical
supervision, i.e., non-traditional settings
such as medispas, where the amount of
supervision is limited. dw
DR. AVRAM is director of the Dermatology Laser
and Cosmetic Center at Massachusetts General
Hospital. His articles appeared in Lasers in
Surgery and Medicine (2015 Feb;47(2):133-40. doi:
10.1002/lsm.22328. Epub 2015 Feb 4) and JAMA
Dermatology (2014 Apr;150(4):407-11. doi: 10.1001/
jamadermatol.2013.7117).
DERMATOLOGY WORLD // May 2015 17
legally speaking
BY ROBERT M. PORTMAN, JD, MPP
Power at the
bargaining table
ANTITRUST RISKS AND ALTERNATIVES FOR DERMATOLOGISTS
EVERY MONTH, DERMATOLOGY WORLD covers legal
issues in “Legally Speaking.” This month’s author,
Robert M. Portman, JD, MPP, is a health care attorney
with Powers Pyles Sutter & Verville PC in Washington,
D.C. Portman is also outside general counsel for the
AAD and AADA.
D
ermatologists, like most other physicians, are
under tremendous economic pressures. Actual and
threatened cuts in the Medicare reimbursement,
along with parallel reductions in private insurance
reimbursement, as well as burgeoning rules, regulations,
and red tape have caused physicians generally, and AADA
members particularly, to ask whether they can form unions
or otherwise take collective action against Medicare or
third-party payers. The goal or hope is to even the playing
field in negotiations with Medicare and private payers. The
reality is that these options raise serious risks under the
antitrust laws. Other less legally risky options are available,
including forming large IPAs or networks, organizing
grassroots campaigns by physicians and patients, or simply
educating physicians about their options. The federal government has also created a broad exception to the antitrust
laws for medical groups and others combining efforts to
form accountable care organizations (ACOs) formed under
the Medicare Shared Savings Program developed pursuant
to the Affordable Care Act.
CAN DERMATOLOGISTS FORM UNIONS TO NEGOTIATE WITH
THIRD-PARTY PAYERS?
The federal antitrust laws prohibit contracts, combinations, and other collective actions among buyers or
sellers of goods that restrain trade. These laws have
regularly been interpreted to preclude collective negotiations by independent groups of professionals, including
physicians. Indeed, attempts by physicians to collectively negotiate with HMOs and other payers have been
a prime target of enforcement actions by the Federal
Trade Commission (FTC) in recent years.
Labor unions, through statutory exemptions in the
federal labor laws, are permitted to collectively bargain
on behalf of their members. But these exemptions apply
only to employees. They do not cover independent contractors. In addition, unions may only bargain on behalf
of non-supervisory employees.
Thus, unions like the Union for American Physicians and Dentists may negotiate on behalf of physicians
employed by hospitals, HMOs, clinics, and the like. In
1999, the National Labor Relations Board (NLRB) ruled
that residents and fellows in private hospitals may also
bargain collectively. However, unions may not negotiate
for self-employed physicians or physicians otherwise acting as independent contractors. Nor may they represent
employed physicians with supervisory or managerial
authority.
18 DERMATOLOGY WORLD // May 2015
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legal issues
Many years ago, the American Medical
Association created a quasi-union called
Physicians for Responsible Negotiation
or PRN. PRN is a physician-based labor
organization of employed physicians whose
members agree not to strike or withhold
essential medical services. PRN, which has
since been spun off into a separate entity,
does not appear to have gained much of
a foothold in the medical community,
probably because it does not offer much, if
anything, more than a state medical society
or a specialty society in terms of advocating
for physician interests.
There is very little chance that the NLRB
or the courts will interpret the labor laws to
allow self-employed physicians to collectively negotiate with hospitals, managed care,
or other similar entities. Indeed, the NLRB
has already rejected union petitions to organize and represent independent physicians.
Likewise, the FTC has taken the position
that unions may not bargain on behalf of
self-employed physicians. The FTC has also
repeatedly attacked efforts by local medical
societies and other loosely knit groups of
physicians to bargain collectively with managed care companies on behalf of otherwise
independent physicians.
The fact that unions may collectively
bargain only on behalf of residents, fellows,
and employed physicians helps account
for the fact that a very small percentage of
physicians are members of unions today.
Therefore, unions provide a very limited
option for dermatologists who are in private
practice or employed by non-union hospitals or academic medical centers. Unions
might become a more viable option as more
and more physicians give up private practice for hospital employment. Until then,
physicians must look to other options.
SHORT OF FORMING A UNION, HOW CAN DERMATOLOGISTS EVEN THE PLAYING FIELD WITH
THIRD-PARTY PAYERS?
Unions are not the only way for physicians
to gain economic leverage against Medicare
SUPREME COURT ANTITRUST RULING RESTRAINS STATES’ ABILITY
TO ENFORCE SCOPE OF PRACTICE LIMITS
A ruling by the Supreme Court in February (North Carolina State Bd. Of Dental
Examiners v. FTC) could make it harder for state medical boards to enforce
scope of practice limits on non-physicians — and expose physicians who serve
on such boards to legal risk.
The Court ruled that a medical board controlled by “active market participants”
could not use the “state action” doctrine to avoid antitrust scrutiny. The
decision is likely to lead to states asserting greater control over medical
boards, which currently operate in a quasi-sovereign manner in many states;
in the future they are likely to be organized as divisions of state health
departments or similar agencies. They may also include fewer “active market
participants” to avoid antitrust concerns.
Moreover, the Court’s ruling in favor of the FTC is a win for that agency’s
campaign to ensure that professional regulatory bodies like medical boards do
not stifle competition in health care services — including competition between
physicians and other providers.
Physicians who serve on such boards or are considering serving may wish
to protect themselves from potential liability by securing state obligations to
defend and indemnify board members.
or managed care. With respect to Medicare,
the American Academy of Dermatology
Association (AADA) and other medical
societies are constantly working to advocate
for more equitable reimbursement policies.
In addition, physicians can engage in civil
protests, such as marches, rallies, and short
work slowdowns. They can also independently decide not to treat Medicare patients
by opting out of the program, or they can
limit the number of Medicare patients they
treat. However, these actions must be taken
carefully to ensure that each physician is
acting independently and not as part of a
group boycott.
With respect to private payers, group
practices can merge to increase their
market power, provided they do not create
a threat to competition in their geographic
area by doing so. Alternatively, physicians can create or join IPAs or physician
networks that meet the antitrust guidelines
for the health care industry that were first
issued by the Justice Department and the
Federal Trade Commission in 1994 and
revised in 1996.
For instance, under the guidelines, IPAs
that use the so-called “messenger model”
are not subject to antitrust enforcement.
The messenger model involves the use of
an appointed individual or entity to act as
an intermediary between individual physician members and the payer. The messenger may not negotiate rates, but may
present proposals by payers to individual
members for their acceptance or rejection.
An integrated physician network offers a
more powerful option for physicians to collectively negotiate with managed care. Under
the DOJ/FTC guidelines, the network will be
protected from antitrust scrutiny if the members share substantial financial risk (e.g., by
accepting capitation) and constitute less than
either 20 or 30 percent of the physicians in
the relevant geographic market practicing
the same specialty, depending on whether
the network is exclusive or not. In some
limited circumstances, the network will be
safe from antitrust scrutiny even if the members do not share substantial financial risk,
DERMATOLOGY WORLD // May 2015 19
legally speaking continued
as long as the network involves significant
functional integration (e.g., utilization review and quality control features) and does
not raise significant anticompetitive risks.
Integrated physician networks can provide their members with substantial leverage against managed care companies and
other payers when they are well organized
and include a substantial number of physicians with large patient rosters. However,
physician networks can also be difficult to
organize and sustain, and too often do not
produce substantial financial returns for
their members.
Short of joining IPA or networks, dermatologists can work through the AADA
to advocate for legislation or regulations to
prevent or punish managed care payment
abuses or to fight Medicare cuts. Medical
societies or other groups of physicians can
also meet with private payers and try to
educate them about the effects of restrictive
reimbursement policies. These advocacy
efforts do not implicate the antitrust laws
as long as the societies or groups do not
threaten to take coercive action against
payers if they refuse to change their policies
in the manner requested by the societies/
groups. The AADA and its dermatologist
leaders have had great success over the
years in counteracting threatened private
payer policy changes that would have had
serious adverse effects on AADA members
and their patients in areas like narrowing
networks, restricted criteria for performing Mohs surgery, and attempts to impose
certification requirements for office-based
surgery.
In addition, medical societies and
other groups of physicians can file lawsuits
against private payers to fight abusive
payment practices. For instance, state
and national medical societies have filed
several class action lawsuits on behalf of
physicians seeking damages and injunctive
relief against managed care companies who
have engaged in patterns of downcoding,
delayed payment, and other abuses. Most of
20 DERMATOLOGY WORLD // May 2015
legal issues
those cases have settled in ways that led to
substantial improvements in the methods
some private payers use to process claims
and pay for medical services.
WHAT ARE THE PROSPECTS FOR CREATING
AN EXCEPTION TO THE ANTITRUST LAWS FOR
COLLECTIVE BARGAINING BY PHYSICIANS WITH
THIRD-PARTY PAYERS?
Despite these alternatives, many physicians
believe the only truly effective way of standing toe to toe with managed care is through
collective bargaining. Thus, organized
medicine has made concerted efforts in
recent years to obtain federal and state legislation to permit collective bargaining by
independent or self-employed physicians.
For instance, bills have been proposed in the House of Representatives to
permit collective bargaining by physicians through an exception to the federal
antitrust laws, although such bills would
not have permitted physicians to strike.
Federal legislation has also been proposed
to apply the so-called “rule of reason” standard to negotiations between a health plan
and two or more physicians, and to award
attorneys’ fees to substantially prevailing
plaintiffs in certain actions against health
plans that act unreasonably or in bad
faith. None of these bills has come close
to passing.
At the state level, Texas passed a law
allowing self-employed physicians to jointly
negotiate patient care and other issues,
including fees, with state supervision of
the process. This law takes advantage of
the “State Action Doctrine,” an exception
to federal antitrust laws under which such
laws do not apply to a state acting in its
sovereign capacity or to private conduct
that is mandated or actively supervised by
a state. Similar legislation has been passed
in New Jersey and Washington. These
state laws are considered to be much more
cumbersome than a federal exception as
they require close state supervision of the
collective negotiation process.
HOW CAN PHYSICIANS FORM ACOS WITHOUT
VIOLATING THE ANTITRUST LAWS?
Dermatologists may be wondering whether
they would be violating the antitrust laws by
forming ACOs to collectively negotiate with
third-party payers, hospital systems, and other purchasers of their services. The answer
is that the Federal Trade Commission and
Department of Justice issued “safety zones”
in 2012 that outline the circumstances in
which otherwise independent physicians and
other health care providers can form ACOs
under the Medicare Shared Savings Program
without violating the antitrust laws. (The
specific requirements of the safety zones can
be viewed in their entirety at www.justice.
gov/atr/public/health_care/276458.pdf.)
While joining an ACO may create a different
set of concerns for dermatologists, being part
of one does create the potential for collective negotiation and for dermatologists to be
prepared as Medicare looks to pay for more
services through alternative payment models. The Academy provides a wealth of information about ACO participation at www.
aad.org/members/practice-and-advocacyresource-center/practice-arrangements-andoperations/aco-and-medical-homes/faqs.
THE BOTTOM LINE
In the absence of federal or state legislation, dermatologists will rarely be able to
form unions to negotiate with managed
care and other payers. Without the ability
to collectively negotiate, physician unions
can do little more than offer the same kind
of advocacy provided by medical societies.
Dermatologists should, therefore, focus
their efforts on alternatives to unions, including creating large, integrated networks,
supporting the efforts of the AADA to work
for better reimbursement policies, as well
as efforts to lobby for legislation at the state
and federal level that allows for collective
negotiations by groups of physicians, and
supporting the efforts of patient advocacy
groups (see From the President, p. 46, for
more on this topic). dw
www.aad.org/dw
ceiling-mounted
procedure light
consultation zone
caregiver
rotates
to the
procedure
zone
supplies within reach
procedure
table rotation large
equipment
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controls
RETHINK
THE
CLINICAL
SPACE.
Patient education. Consultation. Procedures.
Where will you do all of this?
Midmark can help.
We have reengineered the concept of the dermatology room to combine
consultation, counseling and procedures all within a seamlessly efficient,
yet intimate environment.
For more information, call 1-800-MIDMARK
or visit midmark.com/RethinkDermatology
Manufactured and/or distributed by Midmark Corporation.
1-800-MIDMARK Versailles, OH
balance in practice
BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR
Sandy
recollections
THREE TIMES EACH YEAR, Dermatology World
highlights the special interest or hobby of a
dermatologist. This month DW talked to John
Wolf, MD, MA, about how he balances his career in
dermatology with his passion for collecting sand
from around the world. Want to be featured, or know
someone who should be? Email [email protected].
“The beauty of collecting
anything is that you enjoy
the object, but probably
more than the object itself,
you enjoy remembering
where and when you
collected it.”
22 DERMATOLOGY WORLD // May 2015
I
n his study at his home in Houston, John Wolf, MD, has amassed
a vibrant cornucopia of memories.
These memories are not pictures
of various people, places, or objects.
Rather, Dr. Wolf houses more than
100 glass bottles of sand from
around the world.
Dr. Wolf is currently professor
and chair of the dermatology department at Baylor College of Medicine
and practices at the Jamail Specialty
Care Center in Houston. He started
collecting sand when he was a Peace
Corps doctor in the Marshall Islands
in Micronesia for two years. Dr.
Wolf lived on an atoll called Majuro
and sailed to other atolls such as
Likiep, Jaluit, and Ailinglaplap. “I
saw many beautiful islands and
beaches and got interested along
the way in collecting sand. It was an
embryonic activity at the time,” Dr.
Wolf remembers. “Later, I started
tying it in with travel. Wherever I
traveled — to beaches in Hawaii,
the Caribbean, or other parts of the
world — I started collecting sand.”
Dr. Wolf enjoys collecting in
general. “I’m a collector. I have collections from pre-Columbian art to
wine, masks, and Chinese fortune
cookie aphorisms. I also like to
travel.” Dr. Wolf has visited six of the
seven continents and has lectured
in 25 foreign countries. “Travel plus
the instinct for collecting is what led
me to perpetuate the sand collection.” From pink to black, each vial
of sand is different and is labeled by
date and location. Each serves as a
token reminder for Dr. Wolf of the
different experiences and events
throughout his life and career as a
physician.
www.aad.org/dw
management insights
THE COLLECTION
MARKING MEMORIES WITH SAND
When Dr. Wolf travels and there is sand to collect, he will collect it.
Dr. Wolf only takes a few ounces of sand, so as not to disturb the
environment, and places it in plastic baggies to bring home. His
wife purchases glass bottles of various sizes and shapes, and the vials are then filled, labeled, and placed on shelves in his home office.
Several bottles are in his office at work as well.
One of Dr. Wolf’s favorite samples is the sand he collected on St.
John, in the U.S. Virgin Islands, where he and his wife were married. “The beauty of collecting anything is that you enjoy the object,
but probably more than the object itself, you enjoy remembering
where and when you collected it.”
Dr. Wolf keeps most of his sand collection and other
collectibles in his home office.
White sand from Majuro and Whitehaven Beach, and black
sand from Hawaii.
THE COLLECTION CONNECTION
WHITE SAND FROM MAJURO
Dr. Wolf has collected a number of his specimens while traveling
and lecturing about dermatology. The whitest sand in Dr. Wolf’s
collection is from Whitehaven Beach on the Great Barrier Reef in
Australia, which he collected when he was there for the World Congress of Dermatology meeting in 1997. The second whitest sand is
from the island of Majuro (pictured here) where he did his stint as a
Peace Corps doctor and started his interest in collecting sand.
Dr. Wolf shows pictures of beaches around the world often during
his lectures, and sometimes he brings sand to show the audience.
“To me, the most important aspect of talking about dermatologists’
hobbies or extracurricular activities is to show that dermatologists
are interesting people who like to do a lot of unusual things. You
have dermatologists who collect art, wine, antique books, shells,
minerals, and fossils. The overarching theme is that dermatologists
don’t just do dermatology.” dw
Sand from Majuro in a Zen garden reminds Dr. Wolf of his
time in the Peace Corps.
Pink sand from Guam, white sand from the Great Barrier Reef,
and black sand from Hawaii.
To see more of Dr. Wolf’s collection, visit www.aad.org/dw.
DERMATOLOGY WORLD // May 2015 23
answers in practice
Managing a
small practice
IN THIS MONTH’S Answers in Practice column,
Dermatology World talks with Elizabeth S.
Jacobson, MD, about managing a small
practice and ensuring quality and timely patient
experiences at Inverness Dermatology & Laser
in Hoover, Alabama.
DERMATOLOGY WORLD: Tell us about your
practice.
DR. JACOBSON: Inverness Dermatology & Laser now
has three physicians, Shellie Marks, MD, Kathleen
Beckum, MD, and me. We also have one physician assistant, Mary Beth Templin, PA-C, and 17 amazing staff
members. Our practice sees about 150-180 patients per
day. This number will increase as our third physician
builds her practice.
You were in a multi-specialty clinic for about
seven years before starting your own practice.
What inspired you to go the private practice route?
DR. JACOBSON: I was hesitant to go out on my own
because I was not experienced in business and was busy
with three children, including a new baby. My former
practice had wonderful patients and I enjoyed having interaction with the other multi-specialty doctors.
However, I wanted to run a smaller practice where I had
better control. The multi-levels of management of my
former practice made improving efficiency difficult and
I was extremely frustrated with the infrastructure of the
practice.
What challenges did you encounter in creating
your own practice?
DR. JACOBSON: In the middle of the recession —
when obtaining financing was no easy task, even for a
physician— we built a building and started a practice.
At first, my top priority was getting patients to come to
me. What if no one came?! We had our first and only
employee scheduling patients on Yahoo scheduler from
her cell phone before we had a building completed. We
did everything from the ground up which was a lot of
work and 24/7 for about two-and-a-half years. I even
designed our first website (and I am not a computer
person). We planned that I would not expect a salary for
the first six to eight months. It was hard work and great
fun designing the building, developing the practice, and
deciding how we were going to do things.
What are the advantages and disadvantages of
running a small practice?
DR. JACOBSON: The advantage is that you get to do
things the way you want to do them. You get to try out
your ideas and decide how you want to run that practice.
That concept makes it sound like you are carefree and
living the dream, but it actually comes with daunting responsibility. You really have to structure your practice to
work well for your patients and your employees which is
no easy feat. When it’s your practice you’re the one who
always takes a pay cut when the money is short, you’re
going to be the one who works extra hours or days when
24 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
management insights
nobody else wants to, and you’re going to be
the one to worry about the overflowing toilet
when everyone has gone home on Friday.
How have your hours changed since
moving to a private practice from a
multispecialty practice?
DR. JACOBSON: I absolutely work longer
hours. I’m doing more things on weekends
and at night. When I am on vacation or
choose to take a day to be the Mystery Reader
at my child’s school, I am all too aware of
the financial impact of my time away from
work. My husband, Keith, is the practice
administrator, so it could be 8:00 pm and
we’re trying to watch Downton Abbey and I
say “maybe we need to change this on the
website” or something like that. It’s really
part of our day-to-day life. Our kids observe
us working together as parents and business
partners and I think it is a unique situation
for them as well.
How do you and your other
physicians ensure the practice has
appropriate coverage?
DR. JACOBSON: It’s very rare that one of
us has to be out due to illness, but if that
happens we just cover each other’s patients
as best we can that day. We always try to have
an MD in the office so the other physicians
and I are almost never out at the same time.
We don’t go to the same meetings for coverage reasons. We don’t take the same time off.
We’re very good at working it out. We never
have an issue where we all need to be out
more than one or two days.
How do you handle the administrative workload (meaningful use,
PQRS) with a small staff?
DR. JACOBSON: I found that if you can get
the providers on board for the changes with
the right attitude, then the staff follows as
well. For example, when we switched to a
new EHR system, we were able to switch
completely from our old method of scanning
our notes, to learning and implementing our
new system in two weeks with no schedule
reduction. It was a painful two weeks but
we have benefited greatly from the change.
It was having the right attitude and saying
“we’re going to do this and it’s going to be
great” and our staff followed this positive
example. A provider that’s resistant and has a
negative attitude about change will negatively influence the staff and lead to failure
implementing a new idea.
What are some time-management
tactics that you and your staff
employ?
DR. JACOBSON: We play with the scheduling quite a bit to make improvements to the
clinic flow. There are not a lot of static decisions. We are always changing, always evolving. A week doesn’t go by where someone
doesn’t say “should we try this or perhaps
change that?” We have “idea” contests in the
office. Everyone comes up with three ways to
improve the patient experience or an office
process and if we implement your idea you
win a gift card or pair of scrubs and are recognized for your contribution. I’ve practiced
for 12 years, and staff comes up with things
that I cannot believe I have not done before.
For example, one of our employees suggested that we make the intake sheet follow
exactly the questions on our EHR so we’re
not skipping around entering information. It
is a simple and easily implemented idea and
it greatly increased our speed in triaging patients. Also, someone suggested we make all
the emails from the website go to everyone
on a single email so that anyone who has a
few minutes can address a couple of emails.
These are simple things that have made
huge positive impacts on our practice!
How do you gauge patient satisfaction?
DR. JACOBSON: We occasionally survey patients on how can we make things better. We
do receive complaints from patients and we
try to use these complaints to make positive
changes. We also get very nice comments
and notes from patients and we put them in
an album in a lobby. I think that is wonderful for new patients to start out with us with
the thought that they will be treated well and
that we truly care about them.
As a small practice, what type of marketing do you employ?
DR. JACOBSON: Having patients sent to us
by word of mouth is our favorite way to get
new patients. They are already coming to us
because a current patient is happy with our
care and that starts us out on the right foot.
Nothing promotes our practice better than a
current patient saying, “I really liked them.
You should go to them.”
What is the key to running a
successful small practice?
DR. JACOBSON: In addition to practicing
medicine, while running a business you
have to wear two hats and that’s very difficult
without having a really great staff that you
can rely on who pay attention to details and
care for your patients. Without my office
manager of seven years, Lindsey Schoenfeld,
who manages our employees, billing, and
basically every detail and hiccup in our dayto-day operation, we couldn’t have the business we have today. My husband — as the
practice administrator — does the banking
and accounting, dealing with vendors, managing banking issues, paying bills, managing
employee benefits like our 401(k), profitsharing, health insurance, etc. He is excellent at managing this practice as a successful
business. I believe that our practice is one of
the most efficient and well-run practices. We
are very good about staying on top of things
and making sure that we are running things
as efficiently as possible without cutting
corners in providing excellent dermatologic
care for our patients.
What advice would you give a
physician considering starting their
own practice?
DR. JACOBSON: I would recommend that
everyone start at an established practice
because I think you must first develop confidence in your clinical skills. It is also crucial
to see how businesses are run because we’re
not taught that in residency. I really benefited from having several years of observing the management of my former practice
and developing my own ideas about how I
wanted my practice to be.
Dr. Jacobson is in private practice at Inverness Dermatology and Laser in Hoover,
Alabama. dw
DERMATOLOGY WORLD // May 2015 25
GARGANTUAN
GROWING GENERIC PRICES
Soaring prices force dermatologists to
rethink common therapies
26 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
BY RUTH CAROL, CONTRIBUTING WRITER
P
rescribing treatments that best combine efficacy and affordability
used to be as easy as prescribing a generic. But with the recent
escalation of generic drug prices, dermatologists are finding
themselves having to rethink some common treatment therapies,
substituting them more often, and taking additional steps to assist their
patients in obtaining the medications they need. Dermatologists are
finding themselves broaching this topic more frequently with patients —
something not all of them are comfortable doing.
Meanwhile, the AAD staff and its Regulatory Policy Committee are
conducting an environmental scan and analysis to define the problem,
noted Adam Rubin, MD, committee chair. Although the soaring cost of
generic medications is a problem throughout the house of medicine,
the AAD is hearing from members that these steep price increases
are making it increasingly difficult for their patients to afford their
medications, he said. The AAD is forming a Task Force on Drug Pricing
and Drug Pricing Transparency to gather specific data about how this
problem is affecting dermatology in particular. “We need to move
from anecdotal reports to defining the problem in order to have a
comprehensive action plan,” Dr. Rubin said. >>
DERMATOLOGY WORLD // May 2015 27
GARGANTUAN
GROWING GENERIC PRICES
DERMATOLOGISTS’ EXPERIENCES
IMPACTING PATIENT CARE
“Like many dermatologists around the country, I have
increasingly experienced problems with the availability
and wild price fluctuations for generic topical and oral
medications that were previously inexpensive and easy
to find,” noted Jack Resneck Jr., MD, professor and
vice-chair of dermatology at the University of California
San Francisco School of Medicine. “The frustration
that my patients and I experience is exacerbated by the
fact that some of these generic drugs seem to disappear
from pharmacy shelves or skyrocket in price suddenly
and without notice or any predictable patterns.”
Like Dr. Resneck, many dermatologists have
learned about price spikes or drug shortages from their
patients who are trying to obtain a medication. This
scenario leads to significant disruptions in clinical care,
he noted. “It’s darn near impossible for doctors to try
and stay current on what a drug costs. I end up relying
on my patients to say that their insurance won’t cover
a particular drug,” echoed Mary Maloney, MD, former
chair of the AAD’s Regulatory Policy Committee and
chief of the division of dermatology at the University of
Massachusetts. “I didn’t know there was a tetracycline
shortage until I tried prescribing it and a patient
couldn’t get it.”
Also increasing are the patients’ out-of-pocket
expenses as pricier generics are being moved to
a higher co-pay tier and dropped from discount
generic drug programs. Dr. Rubin has noticed that
insurance plans are rejecting fewer prescriptions
as of late. In the past, an insurance plan might
reject a prescription, but pay for a similar one on its
formulary, he said. Now, the insurance covers the
first-choice medication, but with a very high co-pay.
As a result, Dr. Rubin has altered treatment plans
based on the patient’s ability to pay for medications
and substituted medications that may not be as
efficacious.
Although the significant cost increases bother
Dr. Maloney, they haven’t stopped her from
prescribing certain medications provided that the
patient’s insurance covers it. As an example, Dr.
Maloney continues to prescribe doxycycline as it is a
tremendously effective drug for treating communityacquired Methicillin-resistant Staphylococcus aureus
or MRSA. On the other hand, when the medication
is not covered by insurance, and there are other
treatment options, she will push topicals and hold off
on prescribing an oral antibiotic, such as minocycline.
TRACKING $KYROCKETING PRICE$
In the summer of 2013, Peter Reisfeld, MD, a former president of the Long Island Dermatologic Society (LIDS)
and current treasurer of the New York State Society of Dermatology and Dermatologic Surgery (NYSSDDS),
began noticing sharp price increases for generic topicals, particularly desonide, after receiving complaints
from numerous patients. His pharmacist informed Dr. Reisfeld that the cost of several medications, many of
which were dermatologics, was rising rapidly.
To begin documenting the problem, he reviewed the federal database on the Medicaid.gov website that contains weekly surveys of pharmacy costs for tens of thousands of drugs. These surveys, which are dated and
posted online as Excel spreadsheets, are used to help states calculate reimbursements for the Medicaid
program, he explained. “By combining data from different dates, calculating ratios, and sorting the data, I was
able to demonstrate the actual increases that were taking place,” said Dr. Reisfeld, who brought the issue to
the attention of the NYSSDDS board of directors in September 2013. Three months later the data was posted
to the LIDS website with a link from the NYSSDDS website. The data include cost information for topical dermatologics sorted by name, package cost, and price increase. Also available for download is a spreadsheet
containing current pricing for all medications sorted alphabetically. This information will allow physicians “to
accommodate the financial needs of patients with limited insurance coverage, and to maximize value for the
healthcare system,” the website reads. Dr. Reisfeld also used the data as the basis of an editorial published in
Cutis in January 2014.
28 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
“The good news is there are a lot of good drugs for
treating acne, so I can substitute other medications,”
Dr. Maloney said. She also relies on some tricks of the
trade such as using a less potent topical steroid but
wrapping the affected area with plastic wrap to increase
the steroid’s penetration and strength. Dr. Maloney has
stopped prescribing tetracycline. “It’s hard to imagine
why tetracycline, which is dirt cheap to make, is now so
expensive, that is, if you can find it,” she lamented.
Peter Reisfeld, MD, has started to factor in the price
of a medication in addition to its effectiveness. “If I can
find a medication that is equivalent in effectiveness at a
lower cost, that’s the one that I am going to prescribe,”
he said. Within dermatology, there are many different
generic medications that could be equivalent but at
varying price points. “So you still have the ability to
choose a less expensive generic if you know which ones
are expensive,” Dr. Reisfeld said.
These unpredictable price fluctuations have
become part of the treatment discussion, which
Dr. Rubin, for one, finds awkward. “It can be
uncomfortable to talk to patients about their financial
ability to pay for prescriptions. The ability to pay for
medications can be linked with independent financial
issues in other spheres of their lives.” he said. Still,
Dr. Rubin does feel obligated to inform patients of
the potential high cost of generic medications, which
patients may not be expecting to be the case.
Dr. Reisfeld is often amazed at how some of the
costs have gone up so dramatically, he noted, as are
many of the pharmacists he works with; patients
whose insurance does not cover the increases are
often discouraged or angry. Aside from increases in
acquisition costs, another problem particularly for
uninsured consumers is pharmacy markups, he said.
Dr. Reisfeld recently prescribed topical imiquimod
for a patient who called to say that it would cost
$625 to fill the prescription at a large pharmacy
chain. However, the pharmacy at Costco, which has
a policy of charging a maximum 15 percent markup
over its cost for generic medications, was selling the
same prescription for $91. “When I’m prescribing a
medication that is more costly and I know has a lot
more variability in pricing, I will often tell the patient
to shop around,” he said. “I think patients really
appreciate when you’re trying to save them money.”
REASONS CITED FOR THE SHORTAGE
Dermatologists speculate that there may be myriad
reasons for the price increases. High on the list of
Using the same database, Philadelphia-based Pembroke Consulting released an analysis in August 2014
noting that half of all generic drugs sold through retailers had become more expensive during the past year,
with a median increase of nearly 12 percent. Moreover, the cost of one out of 11 generics more than doubled,
while the prices of others skyrocketed. Among the findings: the cost of a 500-milligram capsule of tetracycline rose from 5 cents to $8.59, representing a nearly 18,000 percent price hike, while a 250-mg capsule
increased from 6 cents to $4.26, a more than 7,000 percent increase. The price of a 100-mg tablet of doxycycline hyclate rose from 6 cents per pill to $3.65. The cost of fluconazole rose from 14 cents to $1.50. The price
of a 60-gm tube of generic desonide cream jumped from $26.75 to $248.04.
When Dr. Reisfeld updated the data posted to the LIDS’s website in October 2014, he noted that tetracycline
was still high on the list. With a 179-fold price increase during the past year, the monthly cost of 500-mg BID
dosing jumped from $2.89 to $518. Other oral medications with dramatic increases include a 60-fold increase
in the cost of captopril, a 26-fold rise in the price of amitryptyline, and a nearly 18-fold increase in the cost of
carbamazepine. Certain formulations of topical clobetasol have had a nearly 20-fold increase, as well. The cost
of a 45-gm tube of 0.025 percent generic tretinoin cream jumped from $25 to $150. A 45-gm tube of hydrocortisone valerate rose from $27 to $110. Many generic formulations of topical steroids have increased at least
four-fold in the past two years, along with generic hydroquinone, clindamycin solution, and ciclopirox solution.
This past December, the cost of econazole increased six-fold within a few months, Dr. Reisfeld added.
DERMATOLOGY WORLD // May 2015 29
GARGANTUAN
GROWING GENERIC PRICES
possible culprits is industry consolidation. A significant
number of mergers and takeovers have occurred in the
pharmaceutical industry in recent years, leaving the
market with fewer companies manufacturing generics,
Dr. Rubin said. Less competition equals higher costs.
“In 2010, four of the top generic manufacturers
accounted for 50 percent of all generic prescriptions in
the United States,” he said. Increased regulation by the
FDA may both encourage producers to drop products
or discourage new competitors, Dr. Reisfeld added.
“Once prices go up, the huge FDA backlog on approval
of new generics prevents competition which could
bring prices back down.”
Some manufacturers exit the market if the profit
margins are insufficient, Dr. Maloney noted. They
may abandon a drug if it is too difficult, costly, or time
consuming to make.
Manufacturing glitches and FDA crackdowns
on manufacturing plants can cause both supply
disruptions and production lapses. According to
extensive research done by Erin Fox, PharmD, a
professor in pharmacotherapy at the University
of Utah, some of the factors making the supply
chain so fragile include global outsourcing of raw
materials, tighter supply inventories, consolidation
of manufacturers and suppliers and a lack of
manufacturing redundancy, business decisions
to purposely limit production, and serious quality
control problems leading to regulatory enforcement
that may include factory shutdowns.
BILL$ TO LOWER THE BILL
Many members of Congress have introduced bills to address issues around generic drug pricing. As an
example, Representatives Doug Collins (R-Ga.) and Dave Loebsack (D-Iowa) introduced the Generic Drug
Pricing Fairness Act (H.R. 4437), which would provide further transparency of payment methods PBMs use
to reimburse pharmacies for generic prescription drugs under Medicare Part D, and the MAC Transparency
Act (H.R. 5815), which would extend the same remedies to the military’s TRICARE program and the Federal
Employees Health Benefits Program. They are expected to re-introduce H.R. 5815 this year. Similarly, the
Centers for Medicare and Medicaid Services finalized a regulation in 2014 that would require PBMs, starting
in 2016, to update generic pricing benchmarks used in Medicare drug plans every seven days.
TRACKING $KYROCKETING PRICE$
Senators Amy Klobuchar (D-Minn.) and John McCain (R-Ariz.) introduced drug importation legislation to help
In the summer of 2013, Peter Reisfeld, MD, a former president of the Long Island Dermatologic Soreduce the costs of prescription drugs for American families. The Safe and Affordable Drugs from Canada
ciety (LIDS) and current treasurer of the New York State Society of Dermatology and Dermatologic
Act, which was re-introduced in January, would allow individuals to import prescription drugs from Canada.
Surgery (NYSSDDS), began noticing sharp price increases for generic topicals, particularly desonide,
after receiving
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aid Generic Drug Price Fairness Act, S. 2948 and H.R. 5748, would amend the law to extend this rebate provithat contains weekly surveys of pharmacy costs for tens of thousands of drugs. These surveys, which
sion to generic drugs. The Congressional Budget Office suggests that this proposal would save the Medicaid
are dated and posted online as Excel spreadsheets, are used to help states calculate reimbursements
program $500 million during the next 10 years.
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cost,
and price
agreements
postpone
thecost
market
availability
generic
drugs, on average,
byname,
17 months.
Sen.
Klobuchar
says
increase.
Also
available
for
download
is
a
spreadsheet
containing
current
pricing
for
all
medications
that the Preserve Access to Affordable Generics Act could save $4.7 billion for the U.S. budget and $3.5 billion
sorted alphabetically.
This information
will allow physicians
“to accommodate
the agreements
financial needs
for consumers.
In FY 2013, 29 patent
dispute settlements
created potential
pay-for-delay
be-of patients
with
limited
insurance
coverage,
and
to
maximize
value
for
the
healthcare
system,”
the
website
tween branded and generic drug companies, the FTC reported in December 2014. The 29 settlements involve
reads.
Dr. Reisfeld also
used the
as the basis
ofU.S.
an editorial
in Cutis
in billion.
January 2014.
21 branded
pharmaceutical
products
withdata
combined
annual
sales ofpublished
approximately
$4.3
30 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
The most significant manufacturing glitch driving
prices up is a raw material shortage, as in the case
of tetracycline and doxycycline. As far back as two
years ago, pharmaceutical manufacturers reported
discontinuing production of tetracycline, some due
to a lack of active ingredient and others for reasons
that are unclear. The generic was reintroduced
and both the American Society of Health-System
Pharmacists and FDA reported that the shortage
was resolved in March 2014. “Yet the price is still
astronomical,” said Dr. Reisfeld, who is skeptical as to
how much of a role material shortages play in these
price spikes. Sometimes a drug suddenly escalates in
price and then seems to vanish. “But they don’t really
disappear,” he explained, “it’s just that independent
pharmacies are leery to order them.” Since it can take
several weeks for the third-party payers to increase
their reimbursements, pharmacies that order a
medication too soon can suffer substantial losses.
Rather than taking the loss, the pharmacists say they
just can’t get the medication, he said.
LEGISLATIVE EFFORTS
That is why in January 2014, the National Community
Pharmacists Association (NCPA) asked congressional
leaders to hold an oversight hearing to investigate
the reasons behind the skyrocketing costs of generic
drugs, which represent approximately 86 percent
of all prescriptions dispensed in the U.S., according
to a 2014 report by the IMS Institute for Healthcare
Informatics. In October 2014, Sen. Bernard Sanders
(I-Vt.) and Rep. Elijah E. Cummings (D-Md.)
launched an investigation, sending letters to 14 drug
manufacturers requesting information from 2012
to the present, including total gross revenues from
sales of the drugs, prices paid for the drugs, factors
that contributed to decisions to increase prices, and
the identity of company officials responsible for
setting drug prices. At the November hearing of the
Senate Subcomittee on Primary Health and Aging,
an NCPA representative testified about the lag in
reimbursement rates provided to pharmacists by
pharmacy benefit managers (PBMs) that have resulted
in significant revenue losses. According to a member
survey, NCPA found that nearly 86 percent of more
than 1,000 pharmacists reported that it took PBMs
or other third-party payers as long as six months to
update their reimbursement rates to pharmacies,
resulting in reimbursement rates significantly less
than the acquisition costs.
Moreover, several pieces of legislation, many of
which were bipartisan, were introduced in Congress
EHRS OFFER DRUG
PRICING INFORMATION
Electronic health records (EHRs) can inform
dermatologists of what medications are on the
patient’s formulary; some also indicate the cost.
EMA, Modernizing Medicine’s EHR system, can
indicate if a medication is on the patient’s formulary, and if so, what tier it’s on, said Michael
Sherling, MD, the company’s medical director.
Dermatologists can also give patients e-coupons if the pharmaceutical company is running
a promotion. “Dermatologists want to prescribe
drugs that their patients can afford because
they know these drugs will get used,” he added.
Nextech’s EHR also indicates if there is a
generic alternative and displays the co-pay
amount for the medication, noted David Henriksen, the company’s CEO. Prior authorization, which is the next step in the automation
of electronic prescriptions, is becoming a
significant issue as drug prices increase, he
added. Although it won’t solve the skyrocketing
costs, it will improve price transparency. “Prior
authorization will move us from knowing what
medications are on the formulary to what level
on the formulary and how much is covered, and
what the insurance carrier will approve if the
drug isn’t on the formulary,” Henriksen said.
“This helps dermatologists have a very open
conversation with their patients about the drugs
they’re prescribing and how much money their
patients will have to pay out of pocket.”
Peter Reisfeld, MD, noted that an EHR is a good
tool for quickly accessing drug pricing information. “Usually they provide average wholesale
prices, which are only an approximation of true
costs,” he said, “but they still give you a good
general idea about pricing.”
DERMATOLOGY WORLD // May 2015 31
GARGANTUAN
GROWING GENERIC PRICES
last year. (See sidebar for a description of the various
bills.) But as Dr. Rubin put it, “Unless the legislation
is ultimately signed into law, it is just a discussion.”
Dr. Reisfeld believes that legislative efforts might
reduce drug costs for a select patient population, but
will not resolve the problem. He is also concerned
that legislation may limit the potential benefits to
suppliers, risking driving more of them out of the
market, which could worsen the problem.
But before devising a solution, the causes behind
the escalating costs of generic drugs have to be
determined. “The first thing I would recommend
is an expert economic analysis because there is
still quite a bit of murkiness as to exactly what is
responsible,” said Dr. Reisfeld, who is not optimistic
that the drug companies will cooperate given that
they refused to testify at the recent congressional
hearing. (Similarly, drug companies contacted for
this article did not respond to interview requests or
written questions.)
doesn’t work well to keep generic medication prices
down is that insurance reimbursement insulates
patients from the high prices, Dr. Reisfeld explained.
Consequently, demand remains high. “If physicians
become more familiar with drug pricing, then they
will be in a better position to choose treatments
that are effective without being overpriced,” he said.
“Reduced demand from physician prescribing may
help to actually bring prices down. That way we can
help to protect both the medical and the financial
health of our patients.” Dr. Reisfeld encourages
dermatologists to talk to their local pharmacists about
the price surge, check their e-prescribing programs
for drug pricing information, and/or download
the drug database posted on the LIDS website (see
sidebar, “Tracking skyrocketing prices”).
“We will need to be more proactive in becoming
more educated about pricing of medications,” Dr.
Rubin concurred. dw
WHAT CAN DERMATOLOGISTS DO?
In the meantime, there is one thing that physicians
can do. One of the reasons that supply and demand
PAYING LE$$ FOR GENERIC$
TRACKING $KYROCKETING PRICE$
With the cost of prescriptions factoring more into the conversation about treatment options these days, dermatologists can offer their patients some money-saving advice. Simply put, it may pay to shop around.
In the summer of 2013, Peter Reisfeld, MD, a former president of the Long Island Dermatologic So(LIDS)
and current
treasurer
of the
New York
State
Society
of Dermatology
and Dermatologic
Several ciety
national
retailers
and grocers
offer
discount
generic
drug
programs
for individuals
who either
Surgery
(NYSSDDS),
noticing
sharp
price increases
generic
topicals,Among
particularly
don’t have
insurance
or theirbegan
insurance
doesn’t
adequately
cover for
their
medications.
them desonide,
are CVS,
after receiving
from Rite
numerous
patients. His
informed
Dr. programs
Reisfeld that
Good Neighbor,
K-Mart,complaints
Kroger, Target,
Aid, Walgreens,
andpharmacist
WalMart. Many
of these
do the
not cost
of several
medications,
many of
which weretodermatologics,
was rising
rapidly.
have complex
eligibility
requirements,
applications
fill out, or a long-term
commitment
akin to Medicare
Part D. The Walgreens Prescription Savings Club and the CVS Health Savings Pass, however, do have an anTo begin documenting
theWalmart,
problem, for
he reviewed
federal
database
on prescription;
the Medicaid.gov
nual membership
fee. Target and
example, the
charge
$4 for
a 30-day
$10 website
for a 90-day
that
contains
weekly
surveys
of
pharmacy
costs
for
tens
of
thousands
of
drugs.
These
surveys,
which
supply of gentamicin, hydrocortisone, silver sulfadiazine, and triamcinolone of varying strengths. Tetracycline
are
dated
and
posted
online
as
Excel
spreadsheets,
are
used
to
help
states
calculate
reimbursements
is no longer on the $4 prescription drug list. Walgreens offers a 30-day supply for $5 (tier 1), $10 (tier 2) or
Medicaid
program,
he explained.
“By combining
data frompropionate
different dates,
calculating
ratios,
$15 (tierfor
3); the
a 90-day
supply
is double
the price, respectively.
Clobetasol
0.05 percent
gel and
and
sorting
the
data,
I
was
able
to
demonstrate
the
actual
increases
that
were
taking
place,”
said
Dr.
fluconazole are tier 2 drugs, whereas doxycycline, betamethasone, and ciclopirox are tier 3 medications. TriReisfeld,
who
brought
the
issue
to
the
attention
of
the
NYSSDDS
board
of
directors
in
September
2013.
amcinolone falls into tiers 1, 2, and 3, depending on the strength. CVS charges $11.99 for a 90-day supply of
Three
months later the
was postedacetonide.
to the LIDSClobetasol,
website with
a link fromminocycline,
the NYSSDDS
website.
fluconazole,
hydrocortisone,
anddata
triamcinolone
doxycycline,
and
tretinoin
The
data
include
cost
information
for
topical
dermatologics
sorted
by
name,
package
cost,
and
price
are among the dermatologics offered at discounted rates at Costco’s pharmacy.
increase. Also available for download is a spreadsheet containing current pricing for all medications
sorted
This information
will allow physicians “to accommodate
financial
of paWebsites,
such alphabetically.
as www.GoodRX.com
and www.PharmacyChecker.com,
can be used tothe
check
pricesneeds
on pretients
with
limited
insurance
coverage,
and
to
maximize
value
for
the
healthcare
system,”
the
website
scriptions at nearby pharmacies. GoodRx shows the prices, coupons, and discounts, and even offers a free
Dr.savings
Reisfeld
alsoPharmacyChecker
used the data as the
basis of
anand
editorial
published
in Cutis
in January 2014.
app and reads.
discount
card.
verifies
U.S.
international
online
pharmacies.
32 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
Upcoming CME Activities
Closure Course and Dermatologic Surgery: Focus on Skin Cancer
Hyatt Regency Grand Cypress – Orlando, Florida
May 20-21, 2015 – Closure Course
This intense learning experience provides didactic instruction and practical experience in multiple closure
techniques, and includes numerous anatomic site-specific discussions. A hands-on laboratory session allows for
closely-monitored practice of new and complex reconstruction techniques on realistic visco-elastic models.
Information presented in the course strongly complements the activities featured in Dermatologic Surgery:
Focus on Skin Cancer (below), without direct overlap or duplication of material.
May 22-24, 2015 – Dermatologic Surgery: Focus on Skin Cancer
Top experts in cutaneous oncology and dermatopathology will present a multi-faceted program for dermatologists
and dermatologic surgeons. Presenters in interactive panel discussions will share their unique perspectives on
special tumor management, melanoma diagnosis and treatment, and reconstruction challenges. Advanced Mohs
techs will receive updates on quality assurance measures, troubleshooting, safety, and regulatory compliance in
the Mohs lab. Meeting provides an excellent follow-up to our Fundamentals of Mohs surgery technician training.
Basal and Squamous Cell Cancer Pathology for Mohs Surgeons and
Fundamentals of Mohs Surgery
DoubleTree Hotel San Diego, Mission Valley – San Diego, California
November 3-4, 2015 – Basal and Squamous Cell Cancer Pathology for Mohs Surgeons
Taught by Board-certified dermatopathologists, this intense one-day course will provide a “pure pathology”
experience for physicians interested in understanding the subtler characteristics of basal and squamous cell
carcinoma, the tumors most commonly treated with Mohs surgery. Participants will learn to accurately interpret
BCC and SCC in all its variations, as well as to differentiate tumor characteristics from background findings,
reactive changes present in recently biopsied tissue, etc. The Fundamentals of Mohs Surgery course, either the
full meeting or only the slide review portion – where you will be reading a large number of Mohs cases set up
as “unknowns” – is perfect for applying the knowledge gained from this pathology course.
November 5-8, 2015 – Fundamentals of Mohs Surgery
Dermatologists and other specialists will be introduced to the basic surgical and histopathologic aspects of Mohs
surgery, preparing a solid foundation for long-term proficiency in the procedure. Microscope laboratory case
review and pathologist-led small group discussions will promote greater understanding and enhanced accuracy
in this most critical facet of Mohs surgery. Intensive cryostat lab instruction will benefit Mohs technicians at all
levels of training and experience, deepening their understanding of Mohs tissue processing and the importance
of the physician-technician “team” in successful Mohs surgery.
For additional information regarding ASMS educational activities, membership opportunities, and patient resources, please contact:
Novella Rodgers, Executive Director
American Society for Mohs Surgery
5901 Warner Avenue, Box 391
Huntington Beach, CA 92649-4659
Tel: 800-616-2767 or 714-379-6262
Fax: 714-379-6272
www.mohssurgery.org
[email protected]
DECODING DATA
divorced from context
Profiling the missing pieces and implications
of Medicare’s physician payment data
34 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR
W
hen the Centers for Medicare and Medicaid Services (CMS)
released provider payment data for 2012 on April 9, 2014,
many physicians hoped the release would be a one-time
event. With this winter’s announcement that the release will take
place annually, dermatologists may wonder what, if anything, they
should do in response — and may have some questions about their
colleagues to boot.>>
DERMATOLOGY WORLD // May 2015 35
DECODING DATA
divorced from context
It’s natural to wonder, according to Brett
Coldiron, MD, immediate past president of the
Academy, who wrote about the Medicare payment
data released by CMS in his July 2014 From the
President column. “If you looked at data about
any of your colleagues, you may well have had the
same thought as some patients who looked up their
doctors: ‘How do they make so much?’ There may be
a good answer! But without knowing it, the natural
tendency is toward suspicion. That’s what makes
the decision to release the data in this manner
so troubling. It is most important that you not
summarily condemn your colleagues who may have
unique practice arrangements.”
Of the specialties that made up the highestpaid 2 percent of physicians who billed Medicare,
dermatology ranked sixth behind ophthalmology,
hematology/oncology, cardiology, radiation oncology,
and internal medicine. Among this 2 percent were
1,142 dermatologists who were paid a collective
$947,065,872; 246 dermatologists received more than
$1 million in payments from Medicare in 2012. Now
that this information is out for the public’s viewing
and judgment, with another year of data coming
soon, the specialty is left to comb through the data to
get the full picture, and prepare for questions — and
potential criticism — from patients, policymakers, and
colleagues.
OUT OF THE BLUE AND INTO THE PUBLIC’S HANDS
The data release in April 2014 came as somewhat
of a surprise to physicians and organizations alike.
While there had been movement afoot to release some
information, the nature in which the data would be
released was unclear. Releasing these data had been a
topic of debate since the 1970s, but finally came to a
head in May 2013, when a federal judge lifted a 33-yearold injunction that prohibited CMS from releasing any
payment information that could be used to identify
individual physicians. Shortly thereafter, CMS asked
groups like the American Academy of Dermatology
Association (AADA) to weigh in on whether it should
release physician payment information. The AADA —
and many other stakeholders — strongly opposed the
release, advocating for physicians’ right to privacy.
Regardless, in early 2014, CMS announced that it
would consider Freedom of Information Act (FOIA)
requests for physician payment information, and
would weigh privacy interests of individual physicians
against the public interest when deciding whether
to disclose the amounts that were paid to individual
physicians under Medicare. However, given the
significant administrative burden of triaging FOIA
36 DERMATOLOGY WORLD // May 2015
requests, CMS instead released all of the physician
payment information to the public in one fell swoop.
A CASE FOR TRANSPARENCY
According to CMS, the data release was simply an
effort to implement an open-information policy — a
concept that stemmed from a 2013 President Obama
Executive Order that called on all federal agencies to
be more transparent. In a May 2014 opinion paper in
the New England Journal of Medicine, Niall Brennan,
Patrick Conway, MD, and Marilyn Tavenner at the U.S.
Department of Health and Human Services (HHS)
called the data release a move toward a strong “healthdata ecosystem.” “We believe that greater transparency
in the health care system can drive improvement in
health and contribute to the delivery of higher-quality
care at lower cost.”
Accordingly, CMS has high hopes for these data
internally — analyzing coding and frequency patterns
of 6,000 different services and procedures, broken
down by physician, specialty, geographic location,
charges and payments. For example, CMS looked at the
data among specialties for routine office visits (codes
99211-99215), and found that neurologists were more
likely to utilize codes that reimburse more than others
because of the length of time the routine office visits
often take (up to 40 minutes). Dermatologists, on the
other hand, utilized lower-valued codes, indicating a
shorter office visit.
Additionally, CMS looked at the variances between
individual physicians by specialty to determine how
often certain services are provided. According to CMS,
about 26 percent of internal medicine physicians
utilized a longer office visit code (99214) less than
100 times. However, 16 percent provided this service
at least 700 times. The dataset also allows CMS to see
which codes are most often utilized by a specialty and
accounted for the most payments. For dermatology, the
most utilized code was E/M code 99213.
Daniel M. Siegel, MD, Academy past president
and former member and current AAD advisor to
the AMA/Specialty Society Relative Scale Update
Committee — the panel of experts (the AMA RUC)
who make recommendations to CMS on the value
of services — believes that these data can help weed
out the bad apples. “The public can’t really tell who’s
bad but we can,” Dr. Siegel said. Indeed, a year after
the payment data was released reports of Medicare
fraud lawsuits among high Medicare earners are
starting to surface. Florida cardiologist Asad Qamar,
MD — who topped the list of cardiologists and ranked
second among all U.S. physicians — has been sued
by the U.S. Department of Justice for Medicare fraud.
www.aad.org/dw
In the 2014 payment data, Dr. Qamar was listed
as collecting $18 million from Medicare. The case
against Dr. Qamar, however, stemmed from reports
from two whistleblowers prior to the release of the
data. Regardless, while the Medicare data alone likely
won’t generate a fraud claim without a whistleblower’s
validation, it may prove useful in identifying and
substantiating accusations of fraud.
However, Dr. Siegel recognizes that the dataset
has some serious limitations. Although CMS argues
that it can glean important coding and utilization
patterns, many are concerned that the general public
does not have the ability or interest to look beyond
the individual physician’s lump sum payment figure
and dig into the context. “Unless one has a very
sophisticated database program, one simply cannot
mine through this information,” Dr. Siegel said.
“Even though there are a number of databases you
can go to and look up your doctor to see how many
patients they’ve done a procedure on, people aren’t
sure how to put that all together.”
Lawrence Green, MD, a member of the AADA
Health Care Finance Committee and the Mohs
Micrographic Surgery Committee and chair of
SkinPAC, agrees that the information does not
provide transparency to each case, but rather, patients,
policymakers, and physicians alike are only given a
hazy sense of what it represents. “Transparency always
seems to lead to ambiguity unless you know the whole
story, and the majority of people don’t know the whole
story,” Dr. Green said. “If you really want transparency
you have to put it in context, which is much more
difficult.”
THE MISSING CONTEXT
Shortly after the release of data, the presidents of
the AADA, American College of Mohs Surgery, the
American Society for Dermatologic Surgery Association,
the American Society of Dermatopathology, and the
American Society for Mohs Surgery issued a statement
expressing support for transparency. However, the
groups expressed concern that the broad release of
payment data, without appropriate context, could hinder
patients’ understanding about the value of appropriate,
medically necessary health care services. “Part of the
problem with these data is that they are naked data,” Dr.
Siegel said.
Take-home pay versus office expense
Essentially, tethering the term “payment” to a specific
physician implies that the exact amount listed in
the CMS database will end up in that particular
physician’s wallet to spend as they choose. However,
in most cases, this does not necessarily represent the
reality. “The pure raw numbers don’t tell the whole
story. It tells you what they’re getting for Medicare
and not how much they’re getting as a source of
actual income,” Dr. Green said.
RESPONDING TO THE PRESS
The release of CMS Medicare payment data for 880,000 physicians ignited a fire storm of unsolicited attention
from the press. Several stories may have been unbalanced because of the lack of context. “Rest assured, the
media will only publicize the things that make good press and will sell newspapers,” Daniel Siegel, MD, said.
If approached by the media, physicians may focus on the following missing pieces to create a full picture of the
issue:
Actual take-home pay: The amount listed by CMS does not represent take-home pay because it does
not account for the overhead expenses a physician has to pay as a business owner.
Expertise: The physicians listed under ‘dermatology’ are not broken down by different sub-specialists,
which often accounts for the variances in Medicare payments.
Practice patterns: The CMS dataset may not delineate between NPI and groups of physicians. It also
does not explain the percentage of Medicare patients that make up each physician’s patient population.
The AAD can help walk members through potential media requests. Please email your inquiries to the AAD at
[email protected].
DERMATOLOGY WORLD // May 2015 37
DECODING DATA
divorced from context
“One of the things people don’t understand is that
you don’t put that money in your pocket,” Dr. Siegel
said. “The staff that checked the patient in and the staff
member on the phone — they all get paid a salary and
receive benefits and health insurance. You have to pay
your six medical assistants, your nurses, the cleaning
crew, deliveries, gas, water, electricity, supplies. All
these things cost money.”
Additionally, Mohs surgeons have higher overhead
expenses compared to general dermatologists
because of the equipment associated with running
an outpatient surgery center. “It is important for the
public to understand that these payments include
practice expenses,” Dr. Coldiron said. “For example,
someone may say, ‘Wow, that dermatologist is making
out like a bandit collecting $500,000.’ The reality is,
however, that practice expense costs up to 66 percent
of what a dermatologist is paid, so that $500,000 is
really $170,000 after expenses. People don’t realize
that a dermatologist runs a hospital outpatient clinic
with medicine, nurses, medical assistants, secretaries,
operating lights, power tables, etc. An office’s cost
is still about 1/3 of what it costs to deliver the same
service in a hospital clinic.”
Sub-specialties and specialized procedures
The type of subspecialist you are and the procedures
you bill for will certainly alter reimbursement amounts,
according to Dr. Green. Yet the CMS dataset does not
distinguish dermatologists by sub-specialty. He warns
that looking at the payment amount listed for a general
dermatologist and comparing it to that of a Mohs
surgeon is not a fair comparison, “You’ll see a dramatic
difference in the Mohs surgeon’s earnings,” Dr. Green
said. However, “a person will look at this and think
there must be something wrong.”
Another potential confounding factor in the CMS
data involves physicians who provide infusions.
According to Dr. Green, infliximab infusions can cost
the physician up to $30,000 a year per person depending
on how sick the patient is. The dermatologist has to pay
that money up front; however, CMS will reimburse the
physician. “A person will see that the dermatologist made
$30,000 from Medicare on infusion codes. But what
they don’t realize is that the dermatologist paid $30,000,
so they actually broke even.”
Practice arrangements and patterns
Dr. Green maintains that the practice’s patient
population, geographic location, and setup can each
effectively skew the interpretation of the amounts
listed in the CMS dataset as well. “Say I’m the
dermatologist who sees the sickest psoriasis patients
in my area. Of course it costs more money to see these
38 DERMATOLOGY WORLD // May 2015
patients because it costs more money to treat them,
when compared to someone who has mild psoriasis.”
Additionally, if a senior doctor in a practice has
several physician assistants, nurse practitioners, and/
or junior doctors on staff, yet they all bill up to one
National Provider Identifier, CMS could potentially
attribute reimbursement rates for several providers to
one. “The senior doctor will look like they are earning
much more, and the associates will look like they’re
not making anything under Medicare,” Dr. Green said.
Dr. Green adds that if a physician practices in an
area with a high elderly population, the physician will
probably receive more from Medicare compared to
someone who doesn’t see many Medicare patients.
In fact, Dr. Siegel argues that the CMS dataset may
draw attention away from some of the bad apples.
There may be one physician who only treats Medicare
patients. Although they are doing everything correctly,
they may get flagged because their payment levels
appear elevated because of the high number of
Medicare patients. However, “There may be someone
who is doing something illegal but is listed on the
low-end of the Medicare data, because they have the
same bad behavior spread out with CMS and several
insurance companies.” Without all of the information
together, it would not be obvious that something was
wrong with this individual physician’s billing.
PART OF A PATTERN
Although the initial sting of having personal payment
information exposed has numbed a bit, the intention
of CMS to continue to release this information every
year adds to a sense that information privacy is a thing
of the past. “The continuing push toward health care
transparency, including price transparency, appears
inexorable,” said Catherine I. Hanson, JD, Academy
consultant and health care attorney with Whatley
Kallas.
Physicians have already complied with several
other transparency initiatives instituted by CMS.
Physician Compare — a program mandated in the
Affordable Care Act (ACA) — allows patients to
search for a physician by location, specialty, and
other parameters. Soon, Physician Compare will also
allow patients to search physicians’ scores on quality
measurements.
Similarly, the National Physician Payment
Transparency Program — also known as Open
Payments or the Sunshine Act — represents another
effort within the ACA to improve transparency. In
September 2014, CMS published information about
the financial relationships between drug and device
manufacturers and health care providers. While
physicians were given the opportunity to review
www.aad.org/dw
their personal data and dispute information before
it went live, several are concerned that the reported
information has the potential to be misinterpreted.
“For the doctor who is consulting for drug companies,
the Sunshine Act makes sense,” Dr. Siegel said.
“However, there are doctors that don’t take anything
from companies and have no relationships. Yet, when
a drug company drops off a reprint of a medical article
— valued at $50 — suddenly those doctors have to
justify that relationship.”
As CMS continues to hone in on transparency,
physicians are left wondering what other dominoes
will fall. “Everyone’s moving toward transparency. It
seems to be the fashion these days,” Dr. Green said.
“The question is: will other insurers do the same?”
Hanson believes so. “It is common for private payers
to follow Medicare’s lead.” Case in point: Shortly
after the Medicare dataset was released, United
Healthcare, Aetna, and Humana announced plans to
release claims payment data to the public for free. The
database was created by the Health Care Cost Institute
(HCCI) and was launched as a website in early
2015. Unlike CMS’s data, however, the data are not
provider-specific, and include costs of treating specific
conditions by ZIP code.
David Newman, PhD, JD, executive director
of HCCI, echoed the sentiment that transparency
in health care is here to stay when he spoke to
Academy members at the annual AADA Legislative
Conference in September. “Big data is getting bigger
and bigger and it’s getting redefined almost every
day.” HCCI is a nonprofit, bi-partisan group that
holds HIPAA-compliant data on about 100 million
people, dating back to 2007 from both employer and
individual markets, Medicare, and other entities.
The sole purpose of HCCI, he said, is to make this
data available to the public through analytical models
that may help improve the U.S. health care system.
“We are trying to link datasets together so we can
ultimately get to the light at the end of the tunnel,
which is essentially the ability to do research on costeffective care.”
who find themselves at or near the top of these lists
would be best advised to develop an explanation that
puts this information in perspective,” Hanson said.
“Physicians can also use this opportunity to stress the
positives associated with their practices. For example,
a high payment amount generally reflects extensive
experience with a particular procedure.”
Dr. Siegel recommends that physicians look at
their own year-to-year practice patterns as well. “You
can then measure trends. CMS is going to look at
who has cut back, and they’re going to wonder if
somebody cut back because they knew they were doing
something wrong and decided to correct it.” Dr. Siegel
recommends pinpointing the factors that may explain
these trends. For example, did the physician serve as
an association officer causing them to spend less time
with patients? Did they have a sick partner and had to
fill in?
Jeanne De Sa, principal at Healthsperian, a
health care consulting firm, spoke at the AADA
Legislative Conference and called on the specialty
to consider developing additional information that
can supplement data released by CMS and other
stakeholders. “Quality measurement is a science
in its infancy. Yet the need for it has outpaced
the development of it as a science,” De Sa said.
“Ultimately, it’s about how you can use your own data
to advance best practices,” De Sa said. “Where are the
opportunities to show that what you do can improve
health care broadly?”
The fact remains, however: although the public
release of Medicare physician payments was an
attempt to increase health care transparency and
detect fraud and inefficiencies, many physicians
found themselves unfairly on trial because of a lack
of context in the data. As a result, it is clear that more
needs to be done to achieve true transparency. “We
have to get more information to supplement these
data,” Dr. Green said. “If we can get that, we can add
a few more pieces to the puzzle to paint the whole
picture: that we are doing a service and we are doing
the best we can to make people feel better.” dw
USING THE DATA TO BENCHMARK
In addition to negative attention from the press and
peers, according to Hanson, “The biggest concern is
that physicians will be unfairly targeted for audits or
other adverse actions by either the Medicare program
or private payers because the reported payment is
misleadingly large.”
Consequently, there are some
things physicians should be doing to benchmark their
practices. Hanson recommends that physicians take
a thorough look at their data and practice patterns,
and compare that to those of their peers. “Physicians
DERMATOLOGY WORLD // May 2015 39
A faster
PIPELINE
Legislation creates timelines for FDA review of sunscreens
40 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
BY JAN BOWERS, CONTRIBUTING WRITER
T
he long wait for new sunscreen ingredients may finally be
coming to an end. Legislation signed by President Obama last
November was designed to revamp and accelerate the process
by which the U.S Food and Drug Administration reviews the safety
and effectiveness of active ingredients in nonprescription sunscreens.
Among other requirements, the Sunscreen Innovation Act (SIA) creates
timelines for FDA review of the ingredients — a welcome provision for
dermatologists who have been waiting years for eight UV filters widely
used in other countries to potentially become available in U.S. products.
“This is a huge benefit for patients because it gives some definite,
reasonable timelines for the approval process for sunscreens,” says
Adam I. Rubin, MD, assistant professor of dermatology at the University
of Pennsylvania’s Perelman School of Medicine and chair of the AAD’s
Regulatory Policy Committee. “In the past, there were no specific
timelines, so some sunscreen products and components which had
been used for years outside the US without a problem, were unavailable
to U.S. patients. Inside the act there are different timelines for various
components of the process, but the overall message is that there’s
a reasonable time in which one can expect to have an answer, or a
progression of the process that is reliable and timely.” >>
DERMATOLOGY WORLD // May 2015 41
A faster
PIPELINE
EXPEDITED REVIEW
The SIA “essentially obligates the FDA to consider
new applications fairly rapidly, within 16 to 20
months,” says Henry W. Lim, MD, chairman
and C.S. Livingood Chair of the department of
dermatology at Henry Ford Hospital. “Pending
applications would have to be reviewed and acted
on within one year. If the FDA Center for Drug
Evaluation and Research fails to act, the application
is transmitted to the FDA commissioner, who has
60 days to personally make a decision.”
Dr. Lim and Steven Wang, MD, director
of dermatologic surgery and dermatology at
Memorial Sloan Cancer Center, are charter
members of the Public Access to SunScreen
(PASS) Coalition, a group comprised of health
organizations, dermatologists, and sunscreen
ingredient manufacturers who collaborated to
work for passage of the SIA. The legislation
was “a huge accomplishment by the coalition,”
says Dr. Wang. “We all came together and tried
to help legislators in Congress to understand
the issue.” The AAD, though not a member of
the coalition, worked closely with the group in
advocating for the legislation. Dr. Rubin notes that
both the Regulatory Policy Committee and the
Congressional Policy Committee contributed to
letters submitted to the Senate’s Health, Education,
Labor and Pensions Committee to comment on
discussion drafts of the bill.
FILTERS PENDING UNDER TEA
The initial impact of the SIA has been to jumpstart
the FDA’s evaluation of the eight filters currently
in the pipeline. These include the UVA filter
ecamsule; UVB filters octyl triazone, amiloxate,
diethylhexyl butamido trizone, and enzacamene;
and UVA/UVB filters drometrizole trisiloxane,
bemotrizinol (Tinosorb S), and bisoctrizole
(Tinosorb M). Between 2002 and 2009, these
LET’S TALK ABOUT (TALKING ABOUT) SUNSCREEN
Most dermatologists are committed to routine sunscreen use as a critical component of a broader
photoprotection strategy. But do they take the time to counsel their patients to apply sunscreen
daily? Two recent studies, albeit with different results, indicate that more practitioners need to
reinforce the sunscreen messages aggressively promoted by the AAD and other medical societies.
The authors of an article published in JAMA Dermatology (2014;150(1):51-55) analyzed data from the National Ambulatory Medical Care Survey for patient visits from 1989 through 2010, for which sunscreen
was recorded (meaning that the physician noted that sunscreen was currently being used by the patient,
was dispensed in the office, or was prescribed or recommended at that particular visit). The NAMCS collects descriptive data regarding ambulatory visits to non-federal, office-based physicians in the United
States. Analysis of the results by physician specialty revealed that “dermatology visits accounted for
most of the appointments associated with sunscreen recommendation (86.4 percent), followed by visits
with general and family practitioners (9.6 percent).” However, “the mention of sunscreen was recorded
at only 1.6 percent of all dermatology visits,” and “sunscreen was mentioned by dermatologists at 11.2
percent of visits associated with a diagnosis of active or remote history of skin cancer.” The authors note
that some physicians may have provided a sunscreen recommendation but failed to document it on the
survey report, and some may have discussed sunscreen at an earlier visit than the one sampled.
Another survey, published as a research letter in the Journal of the American Academy of Dermatology (72(3):
557-558) queried only dermatologists, and examined the number of patients receiving sunscreen counseling. Co-authors Richard R. Winkelmann, DO, and Darrell S. Rigel, MD, cite the earlier JAMA Dermatology
study and state that their study “aimed to clarify the frequency and nature of sunscreen recommendations
by dermatologists.” The survey questions included how many patients were seen in their most recent two
days of practice, how many patients received sunscreen counseling, what is the dermatologist’s preferred
sunscreen vehicle, number of years in practice, and ZIP code of the practice. The 530 respondents reported
discussing sunscreen with 58 percent of patients (18,090 of 31,253) who were seen over a two-day period.
42 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
filters were submitted for review under the
FDA’s Time and Extent Application (TEA), which
requires that a product be marketed continuously
in other countries for at least five years. The FDA
established the TEA “to address the issue that many
of the new filters were introduced in other parts of
the world, mostly Europe,” explains Dr. Lim. “The
purpose was for the FDA to be able to consider
data generated from outside the U.S. to be used as
part of the application process. The problem is that
this process has been in place for 10 years, and no
approvals from TEA have occurred.”
The FDA moved to break the logjam soon
after the start of the new year. In a blog post
on FDA Voice (Feb. 24, 2015, “Shedding some
light on FDA’s review of sunscreen ingredients
and the Sunscreen Innovation Act”), Theresa
M. Michele, MD, director of the of the Division
of Nonprescription Drug Products in the FDA’s
Center for Drug Evaluation and Research’s Office
of New Drugs, said the FDA needs more data from
the manufacturers of all eight filters in order to
determine whether the ingredients meet the FDA’s
standards for safety and effectiveness. Once that
data is received, “the clock starts running,” says
Amanda Grimm, manager of regulatory and public
policy for the AAD. “They have a prescribed time
within which they can convene a nonprescription
drug advisory committee. That’s the group of
experts that will review the data and present a
recommendation to the FDA.”
Dr. Michele also used the post to address some
“misconceptions about the SIA,” noting that the
law requires deadlines for FDA action, but does
not change its standard for general recognition
of safety and effectiveness. In addition, she
emphasized that the law doesn’t provide the FDA
with additional resources (thus, the agency has
requested funds for implementation as part of
the President’s FY2016 budget), and it doesn’t
OTHER KEY FINDINGS:
Dermatologists in practice five years or less
were far more likely to have discussed
sunscreen than those in practice 30 years or more
(70 percent vs. 47 percent).
70%
5 years or less
10 years or less
55%
47%
59%
30 years +
Dermatologists in practice 10 years or less were
12 percentage points less likely to have a vehicle
preference (15 percent vs. 27 percent).
15%
Dermatologists from the southern U.S. were
4 percentage points more likely to discuss sunscreen
with their patients (59 percent) than those from the
middle or northern regions (both 55 percent).
27%
10 years +
Dermatologists in practice more than 10 years were
9 percentage points more likely to recommend lotion
as a vehicle (11 percent vs. 2 percent), though cream
is the most popular vehicle in all age groups.
2%
11%
10 years or less
10 years +
Although his findings were more encouraging than those of the earlier study, Dr. Rigel, clinical professor of
dermatology at New York University Medical Center, insists that “we need to do better. The onus is on us as
dermatologists to try to help protect our patients, and part of that protection is counseling people on using
sunscreen as part of their overall sun protection regimen.”
DERMATOLOGY WORLD // May 2015 43
A faster
PIPELINE
guarantee that products with additional ingredients
will be approved or on the market in a specified
timeframe. (For current information on the
status of FDA’s review of sunscreen ingredients,
see its SIA Web page at www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/
ucm434782.htm.)
BETTER PRODUCTS, MORE CHOICES
If and when the eight pending filters are approved
for use in the U.S., will that make a material
difference to consumers, who already have a
plethora of sunscreen products to choose from?
Yes, say dermatologists. “The benefits of these
filters are well established and well known,”
Dr. Lim remarks. “Many are quite photostable.
Avobenzone is the best long-wave filter we have in
the U.S., but it degrades when exposed to sunlight.
The manufacturers have added other molecules to
the filter to photostabilize it in the final product,
but having other filters approved in the U.S. which
are long-wave UVA and also photostable would
give manufacturers more options in formulating
sunscreens.” In addition, “most of the filters in the
pipeline are more efficient, so you don’t have to use
as much to be able to absorb the UV radiation. Also,
many are quite large molecules, so theoretically
they should be less likely to penetrate the skin and
induce an allergic reaction.”
Consumers may find products that use the
new filters more aesthetically appealing, especially
in high SPF products, says Zoe Diana Draelos,
MD, a private practitioner in High Point, North
Carolina. “These products waiting for approval,
I think, will provide consumers with much
better photoprotection that’s more pleasant to
wear on a daily basis, and I think it will enhance
compliance,” she says. “A lot of the agents on TEA
applications are basically pigments, like laundry
additives. They work the same way as zinc oxide
IN THE PIPELINE
Based on the Sunscreen Innovation Act, the process and timing for the eight sunscreen Time and Extent
Applications now pending is as follows:
Proposed order for six ingredients:
additional data requested (bemotrizinol,
bisoctrizole, drometrizole trisiloxane, oxtyl triazone,
amoxilate, and diethylhexyl butamido triazone)
FDA acts:
Following
issuance of a
proposed order:
Sponsors have
30 days to request
meeting with FDA
Proposed order for two ingredients: FDA determines
that both ingredients are tentatively classified as not
generally recognized as safe and effective (GRASE)
and misbranded due to insufficient evidence
(ecamsule and enzacamene)
44 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
and titanium oxide, but with those you can’t
push the concentration too high or you make
the skin look white. If you have another filter
that you can put into the formulation, you can
lower the concentration of filters that have sticky
characteristics or those that whiten the skin.”
Simply giving manufacturers a broader choice
of ingredients will result in better products,
says Darrell S. Rigel, MD, clinical professor of
dermatology at New York University Medical
Center. “It’s not that we have awful sunscreens
now; that’s a key point,” he says. “There will just
be more options; we could combine some of these
new agents with the older ones, and come up
with better formulations. There’s no downside to
having these available. I just want the best for my
patients.”
Dr. Rubin says he’s optimistic that the new
legislation will result in “a substantially improved
process and access for Americans to get the latest
innovations in sunscreen. It’s really a victory
for dermatology, because sunscreen is a key
component of skin cancer prevention. Having a
fundamental shift in how the components are
evaluated, and having it signed into law, is a
significant advance.”
A “side benefit” to media coverage of the SIA is
that it brought the issue of photoprotection before
the public, Dr. Wang says. “We have 5 million new
cases of skin cancer each year, yet we still have
teenagers and young adults visiting tanning booths,
and we still have people who don’t use sunscreen.
By talking about the Sunscreen Innovation Act, we
keep drilling away about the importance of ongoing
photoprotection, and the need for education and
the need for behavior changes. This gives us an
opportunity to go beyond sunscreen to emphasize
a comprehensive strategy of photoprotection that
includes avoiding sun, seeking shade, and wearing
protective clothing, hats, and sunglasses.” dw
If the data is insufficient, and the sponsor
provides additional data during the comment period,
FDA has 210 days to make determination and issue
final order if no advisory committee is convened
If GRASE, filter
can be marketed
immediately
Public has
45 days to
submit
comments
Final order
issued:
If the data is insufficient, and the
sponsor provides additional data
during the comment period, FDA
has 270 days to make determination
and issue final order if an advisory
committee is convened
If there is sufficient data, FDA has
90 days following the close of the
comment period to issue a final order
If final order is not issued
by Division of Nonprescription
Drug Products, FDA
commissioner must issue
within 60 days
DERMATOLOGY WORLD // May 2015 45
from the president
academy perspective
BY MARK LEBWOHL, MD
Giving
our patients
the floor
L
ike many specialists, dermatologists are facing an array of challenges that span
beyond our daily patient encounters. In my April column, I mentioned several
of these obstacles — from narrowed networks to restrictions on prescription
medications to onerous administrative burdens on our practices. All of these
issues may appear solely affect us as providers. However, these challenges affect
our patients directly. The more insurance companies and policymakers squeeze
physicians, the less access our patients have to specialists and their valuable care.
Our patients’ interests align with ours to a large degree and they are willing to
help us because of that. As a result, we must partner with our patient advocates
and give their issues the spotlight. We must make 2015 the year of the patient.
In the past, we have seen many examples of how effective patient involvement
can be. Years ago, the precursor to CMS — the Health Care Financing Administration (HCFA) — issued a proposal that would revamp Medicare payments
by changing the way dermatologists code for their services by classifying skin as
one organ. That would have made a comprehensive skin exam the equivalent of
a blood pressure check and would have changed our reimbursements drastically.
Our specialty and many other medical organizations sent hundreds of letters in
opposition to this change. However, the only organization that got a response from
HCFA was the National Psoriasis Foundation. They had pointed out that psoriasis
of the scalp is treated differently than psoriasis of the face, nails, or elbows, and
that each part of the body had to be treated differently. As a result of this strong
patient opposition, the HCFA scrapped its proposal and agreed to count each part
of the skin separately.
Another example of the value of patient advocacy is CMS’s 2014 proposal that
would institute cuts to phototherapy services by up to 60 percent as part of a plan
that would equalize payments between physician offices, hospital outpatient departments, and ambulatory surgery centers. The AADA advocated strongly against
this proposal, but letters from patients came pouring in as well. In the 2014 Final
Rule, CMS delayed finalizing the proposal because our patients made them realize
that instituting this proposal would close many phototherapy units and patient
access to care would be diminished.
46 DERMATOLOGY WORLD // May 2015
Additionally, recently we have been
calling on Congress to repeal and replace
the sustainable growth rate (SGR) formula,
and so have our patients because without
a sustainable Medicare physician payment system, our patients lose access to
care. As a physician who treats psoriasis,
I know that every patient is different and I
often spend a lot of time with each. Their
treatments also require a lot of monitoring.
Patients on methotrexate or cyclosporine
often get my cell phone number because
I want them to be able to call and ask
about drug interactions which could be
dangerous. Many patient advocacy groups
have sent letters in favor of repealing and
replacing the SGR formula because they
recognize that if we are paid less for our
services, we will have to see more patients
to pay the bills. This takes time away from
all of our patients and, most disconcertingly, our sickest patients. At press time,
Congress has passed the SGR legislation.
For more information, visit www.aad.org.
These are just a few examples of
how our issues align with our patients’
and how working together can generate
productive policies and impede dangerous
ones. Going forward, we have a number
of challenges on the horizon that will
require this team approach. I call on all
Academy members to not only get involved
with Academy advocacy activities, but to
support our patient organizations. When
we go to Congress and CMS we are seen
as self-serving. When patients go before
these policymaking bodies, they have a
much louder voice. I encourage the entire
membership to join me in activating our
strongest patient advocacy efforts yet. Give
your patients’ issues the floor. dw
www.aad.org/dw
Precisely.
medicine reimagined
academy update
AAD urges ABD to alter MOC
R
esponding to member concerns about how time-consuming and expensive maintenance of certification has proven,
the American Academy of Dermatology recently initiated a dialogue with the American Board of Dermatology
about how to make the program less cumbersome. On April 2 the AAD wrote to the ABD with specific recommendations for changes, including:
• Alter the rules around self-assessment (component 2 of MOC) such that most ACCME-approved CME activities
would qualify and making them reportable to the ABD through the AAD’s new Online Learning Center (www.aad.
org/olc).
• Create an open-book option for the examination requirement (component 3 of MOC), and alter the exam to a
“learn to competence” model rather than the current pass/fail system. In its its letter to the ABD, the AAD wrote,
“An exam that fails a percentage of diplomates each year is inferior to a system that helps all diplomats learn essential new information and rewards them for doing so.”
• Suspend component 4 requirements for patient and peer surveys. In its letter to the ABD, the AAD wrote that the
ABD should “suspend Part IV MOC until the value of these activities has been established. We believe there is a
crisis of trust in the ABD and that this step is necessary to restore trust and reasonable dialogue.”
The AAD letter followed consideration by the Academy Board of Directors of several resolutions from the Advisory
Board related to MOC. As AAD President Mark Lebwohl, MD, noted in a President’s Message on April 2, “The Academy
has heard the concerns of our members, expressed through Advisory Board Resolutions at the Annual Meeting and
individual comments made directly to Academy leadership. The American Board of Dermatology (ABD), not the Academy,
determines MOC requirements for its diplomates.”
To read the full message and the Academy’s letter to the ABD, visit www.aad.org/education/moc/aad-president-smessage-on-moc.
Board approves new policy, advocacy agenda
THE AAD AND AADA BOARDS OF DIRECTORS approved administrative regulations changing the timing of required
action on membership petitions at its March 23 meeting. Petitions presented at the Annual Business Meeting will be
addressed at the next Board meeting following the close of the Annual Meeting.
The AADA Board approved the 2015 advocacy agenda. Top-tier items on the agenda include access to pharmaceuticals/cost transparency, Medicare physician payment reform, scope of practice/truth in advertising, network adequacy and
transparency, skin cancer prevention/indoor tanning, IPAB repeal, and patient access to anatomic pathology services.
Finally, the Board of Directors selected Thomas Rohrer, MD, as its representative to the Nominating Committee. The
Advisory Board selected Adnan Nasir, MD as its representative to the Nominating Committee; it also elected a new chair,
Terence Cronin Jr, MD, and vice chair, Holly Fritch, MD. Both will take office at the conclusion of the 2016 Annual Meeting. – RICHARD NELSON
48 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
news + events
news + events
DATEBOOK
WHAT’S COMING UP
2016 committee appointment application now open
MEMBERS ARE THE HEART of every association and the American Academy of Dermatology and AAD Association are no different. The Academy is one of the most influential
medical organizations in the world because its members are willing to offer their time
and energy to activities to further advance the Academy’s strategic framework.
Each year, hundreds of dermatologists serve the Academy through our organizational
governance structure and through other service opportunities. The Appointment Selection
Committee, chaired by Abel Torres, MD, JD, Academy president-elect, has begun accepting applications to fill 2016 open appointments.
The 2016 online appointment application is available at
www.aad.org/forms/AppointmentApplication/Default.aspx.
Applications must be submitted by June 30, 2015. Members who are selected to serve
will be contacted in the winter. Letters of recommendation are highly suggested, but are
not required.
Information about specific committees and task forces, committee member responsibilities, and other opportunities is available in the Governance Handbook, available online
at www.aad.org/forms/CCTF/Default.aspx.
Contact Jeanine Coffman at (847) 240-1061 or [email protected] for more information. – JEANINE COFFMAN
Registration, housing for Summer Academy Meeting 2015 opens in May
REGISTRATION AND HOUSING for the Summer Academy Meeting 2015, Aug. 19-23 in
New York City, will be available online at www.aad.org beginning at 12 pm CT, May 20 for
physician, life, and honorary members, and May 27 for all others. Housing reservations at
the New York Hilton Midtown and The London Hotel must be made online in conjunction
with registration for the meeting to receive the discounted housing rate. See the meeting’s
registration website for hotel deadlines and cancellation and change polices. More information about the Summer Academy Meeting 2015 is available at www.aad.org/meetings/
2015-summer-academy-meeting. – SUSAN JACKSON
Make an impact
WHEN YOU REGISTER for the Summer Academy Meeting 2015, you can also make a donation and join
in helping change lives through two vital AAD programs:
SPOT Skin Cancer™ seeks to encourage sun-safe behavior by integrating public awareness and education, providing access to screenings and shade structures, advocating for increased legislation, and
supporting research.
Camp Discovery gives children with chronic skin conditions a life-changing summer camp experience,
where they can build self-esteem and learn they are not alone in their daily struggles.
Your donation will positively impact patients, the public, and our communities! Make your donation as
you complete your online registration for the meeting.
DERMATOLOGY WORLD // May 2015 49
classifieds
PROFESSIONAL
PROFESSIONAL OPPORTUNITIES
OPPORTUNITIES
LAJOLLA, CALIFORNIA
Seeking a BC/BE dermatologist to join
Contact Carrie Parratt at
(847) 240-1770
a busy, well-established, growing
practice. Recently expanded office
just blocks from the Pacific Ocean in
Central Florida Dermatology and Skin Cancer Center (CFD) is seeking an ACMS fellowship trained
Mohs Surgeon and/or a BE/BC General Dermatologist. We are also looking for qualified ARNPs
who have dermatology experience. CFD is located in Winter Haven, FL. Winter Haven is the
home of Legoland and is also known as the Chain of Lakes area. Winter Haven offers the suburb
experience with quick access to Tampa, Orlando, and the beach.
Interested parties, who want to join a busy and successful practice, can submit resumes/CVs to
our Practice Manager, Dan Lackey, at [email protected] or call 863.293.2147
for more information. Please visit us on the web at www.centralfldermatology.com.
If contributing to a team with an expectation for excellence and creating a
balanced and fulfilling life are important to you, St. Vincent Healthcare in
Billings, Montana has the opportunity and community for you!
St. Vincent Healthcare in Billings, Montana seeks U.S. trained BE/BC
certified physician for our Dermatology & Skin Cancer Center
• Full time employed position
• Dermatopathologist in house
• St. Vincent Healthcare’s laboratory is accredited by the College of
American Pathologists (CAP) and our cancer program is recognized
by the Commission on Cancer (CoC) as an Approved Cancer Program
• Full complement of medical specialties available.
• Thriving medical community in a family-oriented suburban location
• Excellent School System
• Abundant recreational activities year round – hiking, skiing, fishing,
biking and camping
• Competitive salaries with productivity incentives
• Start date bonus, Moving Allowances and CME reimbursement
For more information, please contact Therese Teske,
Physician Recruiter at (406) 237-4017 [email protected]
or visit our website at www.svh-mt.org
the world’s best climate. Competitive
salary, incentives, benefits and part-
OCALA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
nership opportunities. Please send CV
to [email protected].
PORTERVILLE, CALIFORNIA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
TAMPA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
BOULDER, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
WEST PALM BEACH, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
MONTROSE, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
CALUMET CITY, IL/DYER, IN
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
GROTON, CONNECTICUT
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
HICKORY, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SOUTHBURY, CONNECTICUT
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SANFORD, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
WATERBURY, CONNECTICUT
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SANTA FE, NEW MEXICO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
************
Billings, Montana listed 4th in cities with highest satisfaction –
Business Insider, Gallup 2014
Manchester & Wolfeboro, NH
APDerm® is a vibrant, growing practice of clinically accomplished and patient-focused dermatologists who practice in a community distinguished as among the best places to live on the east coast/
Boston area.
We are seeking a full or part-time dermatologist/Mohs surgeon to join our group of twelve
board certified dermatologists in a professionally run practice with dermatopathology lab, Mohs
surgery and medical aesthetics. This opportunity would allow a highly qualified dermatologist/
Mohs surgeon to practice with excellent support staff in a collegial practice in our Manchester and
Wolfeboro, New Hampshire offices with competitive salary, benefits and opportunity for practice
ownership. For more information, please contact: Glenn Smith, MHA, Administrator and Chief
Operating Officer, at (978) 849-7501 or email [email protected].
50 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
ad index
PROFESSIONAL
PROFESSIONAL OPPORTUNITIES
OPPORTUNITIES
We gratefully acknowledge the following advertisers in this issue:
WORCESTER, MASSACHUSETTS
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
FREDERICKSBURG, VIRGINIA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
BOUNTIFUL, UTAH
Associate Opportunity. Contact
Karey, (866) 488-4100 or www.
MyDermGroup.com.
WASHINGTON, DC
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
Company Product/Service
American Society for Mohs Surgery...CME........................................................ 33
Bayer Healthcare.................................Finacea..................................................... 9
Care Credit...........................................Patient Financing...........................cover, 3
Hawknad Mfg Industries.....................Clear n Smooth...................................... 15
Midmark...............................................Corporate............................................... 21
Modernizing Medicine.........................EMR...................................................IFC-1
NexTech...............................................EHR....................................................... BC
Officite..................................................AADDermsonline................................. IBC
Valeant Pharmaceuticals....................Onexton................................................ 5-6
VisualDX...............................................Corporate............................................... 47
Recruitment Advertising
Adult & Pediatric Dermatology, PC.................................................................... 50
Central Florida Dermatology & Skin Cancer Center......................................... 50
St. Vincent Healthcare........................................................................................ 50
PRACTICES FOR SALE
MOHS SURGEON
Multiple Part Time Opportunities
Montrose, CO 1-2 days/mo
Enfield, CT
2-3 days/mo
Groton, CT
1-2 days/mo
Tampa, FL
1-2 days/mo
Reno, NV
1-2 days/mo
Hickory, NC
1-2 days/mo
Sanford, NC
2-3 days/mo
Bountiful, UT 3-4 days/mo
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com.
We Buy Practices
•Why face the changes in Health
Care alone?
•Sell all or part of your practice
•Succession planning
•Lock in your value now
•Monetization of your practice
•Retiring
Please call Jeff Queen at
(866) 488-4100 or e-mail
[email protected]
Visit www.MyDermGroup.com
weekly
Dermatology World Weekly.
One email every Wednesday.
Just a few stories.
The ones that really matter.
Because you're busy.
But you still want to know what's going on.
Classified ads are welcomed from dermatologist members of the American Academy of
Dermatology, from dermatology residents of approved training programs and institutions
with which they are affiliated, as well as from recruitment agencies or organizations that
acquire and sell dermatology practices and equipment. Although the AAD assumes the
statements being made in classified advertisements are accurate, the Academy does not
investigate the statements and assumes no liability concerning them. Acceptance of classified advertising is restricted to professional opportunities available, professional opportunities wanted, practices for sale, office space available, and equipment available. The
Academy reserves the right to decline, withdraw, or edit advertisements at its discretion.
The publisher is not liable for omissions, spelling, clerical or printer’s errors. For more
information about classified advertising, contact Carrie Parratt at [email protected].
FOR DISPLAY ADVERTISING INFORMATION, CONTACT:
Ascend Integrated Media, Publisher’s Representatives
Bridget Blaney (Companies A-D and Q-R)
Email: [email protected]
Phone: (773) 259-2825
Cathleen Gorby (Companies E-L and S-T)
Email: [email protected]
Phone: (913) 780-6923
Maureen Mauer (Companies M-P and Tu-Z)
Email: [email protected]
Phone: (913) 780-6633
ADVERTISING STATEMENT:
The American Academy of Dermatology and AAD Association does
not guarantee, warrant, or endorse any product or service advertised
in this publication, nor does it guarantee any claim made by the
manufacturer of such product or service.
THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT
LIABLE FOR OMISSIONS OR SPELLING ERRORS.
DERMATOLOGY WORLD // May 2015 51
facts at your fingertips
data on display
TEEN TANNING DROPPED FROM 2009 TO 2013; SUNSCREEN USE FLAT
I
n a sign that the efforts of dermatologists to change the culture around indoor tanning are having an impact, the National Youth Risk
Behavior Survey, conducted every two years by the Centers for Disease Control and Prevention*, has shown a drop in the percentage of
teenagers who said they used an indoor tanning device in its last two iterations. (To learn more about dermatologists’ efforts on this front,
read last August’s cover story, “Taking on tanning,” at www.aad.org/dw/monthly/2014/august/taking-on-tanning.) The 2013 survey showed
that the likelihood of using an indoor tanning device rises with age — 12th graders are more than twice as likely to tan as 9th graders — and is
four times more common among females than males.
While more teens are heeding warnings about the dangers of tanning, sunscreen use among the age group has hardly budged for a decade. See p. 40 for discussion of how a new law may lead to more sunscreens on the market in the U.S. – RICHARD NELSON dw
Teen tanning and sunscreen usage
20
15.6%
13.3%
PERCENT
15
10
9.0%
10.3%
9.3%
10.8%
12.8%
10.1%
5
0
2005
2007
2009
2011
2013
*The National Youth Risk Behavior Survey is conducted every other spring by the Centers for Disease Control and Prevention. The 2013 version includes responses from 13,583
students in grades 9-12. Visit www.cdc.gov/yrbss for more information.
**Percentage of high school students who said they most of the time or always wore sunscreen with an SPF of 15 or higher when they were outside for more than one hour on a
sunny day.
***Percentage of high school students who said they had used an indoor tanning device, such as a sunlamp, sunbed, or tanning booth one or more times during the 12 months
before the survey.
52 DERMATOLOGY WORLD // May 2015
www.aad.org/dw
Officite made the
process seamless and
the staff was great!
Everything we asked,
they delivered!
A great experience.
-Drs. Menaker & Rodney
Officite client since 2012
Endorsed Web Presence
Provider of the
Dermatologists everywhere will tell you the same thing – we put our customers first. That’s
part of why we’re a leader in healthcare websites and online marketing, and why we’re
trusted by over 30 state and national healthcare associations. We build long-term personal
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Call or visit us online for a Free Web Presence Tour
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